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l|-|m|il:M:ll4. 



HR02305500 



ST. LUKE'S HOSPITAL 



Medical and Surgical 



Reports 



Volume III 
1911 




«BR2AI 




COLUMBIA UNIVERSITY 
EDWARD G. JANEWAY 
MEMORIAL LIBRARY 



cot umbra Ulnit>ei'8U|! 

DEPARTMENT OF 

PRACTICE OF MEDICINE 



College of Physicians and Surgeon* 

437 W68T 6»TH 8ta*«t, Nt« r««K 




Papilloma of Bladder Completely Covering 
the Left Ureteral Orifice 



Same after One Application of the High 
Frequency Current 




Same after Second Application of the High 
Frequency Current. ( Close vision, pros- 
tate not seen in the field) 



Final Result, One Month after the first 
Application. ( Close vision ) 



THE TREATMENT OE PAPILLOMA OF THE BLADDER 
WITH THE HIGH FREQUENCY CURRENT 



ST. LUKE'S HOSPITAL 



Medical and Surgical 
Reports 



Volume III 
1911 




WILLIAM G. HEWITT 
Brooklyn, N. Y. 



COMMITTEE ON REPORT OF THE MEDICAL BOARD 



Robert Abbe, M.D. 
Austin W. Hollis, M.D. 
Francis C. Wood, M.D. 



Editor of the Report — Francis Rolt-Wheeler, Ph.D. 



Managers of St. Luke's Hospital 

OFFICERS 

PRESIDENT 

George Macculloch Miller. 

VICE-PRESIDENTS 

Waldron P. Brown, J. Van Vechten Olcott. 

TREASURER 

H. D. Babcock, 32 Liberty Street. 

SECRETARY 

Hoffman Miller. 

MANAGERS 

Whose terms of office expire respectively on St. Luke's Day, 
October 18th, in the following years : 

1912 1913 

Francis M. Bacon, Henry D. Babcock, 

James May Duane, Stephen Baker, 

William Fahnestock, Waldron P. Brown, 

Anson W. Hard, George M. Miller, 

William M. V. Hoffman, Rev. Henry Mottet, D. D., 

Alvin W. Kreeh, A. Gordon Norrie, 

Hoffman Miller, Henry C. Swords, 

Charles Howland Russell. J. Howard Van Amringe. 

1914 
George Blagden, 
George F. Crane, 
William A. Greer, 
J. Van Vechten Olcott, 
John B. Pine, 
Moses Taylor Pyne, 
Herman C. von Post, 
Richard H. Williams. 

MANAGERS APPOINTED BY ST. GEORGE *S SOCIETY OP NEW YORK 

George Gray Ward, Edward F. Darrell. 

MANAGERS EX-OFPICIO 

The Mayor of the City of The President of the Medi- 

New York, cal Board, 

The British Consul General, The President of the Board 

of Aldermen. 



STANDING COMMITTEES 



EXECUTIVE COMMITTEE 

Waldron P. Brown, Hoffman Miller. 

Stephen Baker, William Fahnestock, 

John B. Pine, Henry D. Babcoek, 

"William A. Greer, George Blagden. 

EX -OFFICIO 

George M. Miller, President. 

FINANCE COMMITTEE 

Anson W. Hard, James May Duane, 

Stephen Baker, Alvin "W. Krech. 

EX-OFFICIO 

H. D. Babeock, Treasurer. 

AUDITING COMMITTEE 

Henry C. Swords, Richard H. Williams. 

MEMBERSHIP COMMITTEE 

J. Howard Van Amringe, Charles H. Russell, 

George Blagden, A. Gordon Norrie. 

EX-OFFICIO 

Hoffman Miller, Secretary. 

COMMITTEE ON LEGACIES AND TRUSTS 

George M. Miller, Charles H. Russell, 

William M. V. Hoffman, Moses Taylor Pyne, 

John B. Pine. 

NOMINATING COMMITTEE 

J. Howard Van Amringe, Stephen Baker, 

Henry D. Babeock, A. Gordon Norrie, 

Charles H. Russell, 
iv 



PASTOR AND SUPERINTENDENT EMERITUS 

Rev. George Stuart Baker, D.D. 



HOUSE OFFICERS 



SUPERINTENDENT 

Rev. George Frederick Clover. 

PASTOR 

Rev. George Frederick Clover. 

ASSISTANT TO THE SUPERINTENDENT 

Rev. Floyd S. Leach, Ph.D. 

ASSISTANT PASTOR CASHIER 

Rev. Francis Rolt- Wheeler, Ph.D. Miss P. Graf. 

APOTHECARY CURATOR 

William V. Byard. Andrew Coats. 

CHIEF ENGINEER 

P. G. Westerberg. 

DIRECTRESS OF NURSES 

Mrs. C. E. Bath. 

ASSISTANT 

Miss F. E. Carling. 

HOUSEKEEPER 

Miss Jennie L. Roberts. 

ASSISTANT 

Miss M. E. Savage. 



HOUSE STAFF 



MEDICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911 



DIVISION A. 
HOUSE PHYSICIAN 

William C. Johnson, M.D. 

FIRST ASSISTANT 

Edward N. Packard, M.D. 

SECOND ASSISTANT 



DIVISION B. 
HOUSE PHYSICIAN 

Edmond R. P. Janvrin, M.D. 

FIRST ASSISTANT 

Julius S. Weingart, M.D. 

SECOND ASSISTANT 



Arthur E. Neergaard, M.D. Herman C. Fuhrman, M.D. 

SURGICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911 

DIVISION B. 
HOUSE SURGEON 

George H. Humphreys, M.D. 

FIRST ASSISTANT 

Frederick J. Echeverria, M.D. 

SECOND ASSISTANT 



DIVISION A. 
HOUSE SURGEON 

D. R. Perry Heaton, M.D. 

FIRST ASSISTANT 

Robert B. Kennedy, M.D. 

SECOND ASSISTANT 

Francis J. McCormick, M.D 



T. Brannon Hubbard, M.D. 

PATHOLOGICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911 
Kenneth R. McAlpin, M.D. Edward C. Perkins, M.D. 

William P. St. Lawrence, M.D. Jesse R. Pawling, M.D. 

MEDICAL— FOR THREE MONTHS ENDING JULY 1st, 1911 



DIVISION A. 
HOUSE PHYSICIAN 

William C. Johnson, M.D. 

FIRST ASSISTANT 

Edward N. Packard, M.D. 

SECOND ASSISTANT 

Francis J. McCormick, M.D. 



DIVISION B. 
HOUSE PHYSICIAN 

Edmond R. P. Janvrin, M.D. 

FIRST ASSISTANT 

Julius S. Weingart, M.D. 

SECOND ASSISTANT 

T. Brannon Hubbard, M.D. 



SURGICAL— FOR THREE MONTHS ENDING JULY 1st, 1911 



DIVISION A. 
HOUSE SURGEON 

D. R. Perry Heaton, M.D. 

FIRST ASSISTANT 

Robert B. Kennedy, M.D. 

SECOND ASSISTANT 

Herman C. Fuhrman, M.D. 



DIVISION B. 
HOUSE SURGEON 

Frederick J. Echeverria, M.D. 

FIRST ASSISTANT 

Arthur E. Neergaard, M.D. 

SECOND ASSISTANT 

Kenneth R. McAlpin, M.D. 



PATHOLOGICAL— FOR THREE MONTHS ENDING JULY 1st, 1911 
William P. St. Lawrence, M.D. Edward C. Perkins, M.D. 

Jesse R. Pawling, M.D. 
vi 



MEDICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911 



DIVISION A. 
HOUSE PHYSICIAN 

Edward N. Packard, M.D. 

FIRST ASSISTANT 

Arthur E. Neergaard, M.D. 

SECOND ASSISTANT 



DIVISION B. 
HOUSE PHYSICIAN 

Julius S. Weingart, M.D. 

FIRST ASSISTANT 

Herman C. Fuhrman, M.D. 

SECOND ASSISTANT 



Edward C. Perkins, M.D. Jesse R. Pawling, M.D. 

SURGICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911 

DIVISION B. 



DIVISION A. 
HOUSE SURGEON 

Robert B. Kennedy, M.D. 

FIRST ASSISTANT 

Francis J. McCormick, M.D. 

SECOND ASSISTANT 

William P. St. Lawrence, M.D 



HOUSE SURGEON 

Frederick J. Echeverria, M.D. 

FIRST ASSISTANT 

T. Brannon Hubbard, M.D. 

SECOND ASSISTANT 

Kenneth R. McAlpin, M.D. 



PATHOLOGICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911 

John R. Ashe, M.D. Kevin D. Lynch, M.D. 

George M. Goodwin, M.D. Morris K. Smith, M.D. 

MEDICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912 

DIVISION A. DIVISION B. 

HOUSE PHYSICIAN HOUSE PHYSICIAN 

Edward N. Packard, M.D. Julius S. Weingart, M.D. 

FIRST ASSISTANT FIRST ASSISTANT 

Arthur E. Neergaard, M.D. Herman C. Fuhrman, M.D. 

SECOND ASSISTANT SECOND ASSISTANT 

William P. St. Lawrence, M.D. Kenneth R. McAlpin, M.D. 

SURGICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912 

DIVISION B. 
HOUSE SURGEON 

Frederick J. Echeverria, M.D. 

FIRST ASSISTANT 

T. Brannon Hubbard, M.D. 



DIVISION A. 
HOUSE SURGEON 

Robert B. Kennedy, M.D. 

FIRST ASSISTANT 

Francis J. McCormick, M.D. 

SECOND ASSISTANT 

Edward C. Perkins, M.D. 

PATHOLOGICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912 

John R, Ashe, M.D. Kevin D. Lynch, M.D. 

George M. Goodwin, M.D. Morris K. Smith, M.D. 

vii 



SECOND ASSISTANT 

Jesse R. Pawling, M.D. 



MEDICAL STAFF 



ATTENDING PHYSICIANS 

Van Home Norrie, M.D. Austin W. Hollis, M.D. 

Samuel W. Lambert, M.D. Francis C. Wood, M.D. 

ASSOCIATE ATTENDING PHYSICIANS 

Henry S. Patterson, M.D. Frank S. Meara, M.D. 

Lewis F. Frissell, M.D. 

ASSISTANT ATTENDING PHYSICIANS 

Walter A. Bastedo, M.D. Norman E. Ditman, M.D. 

Karl M. Vogel, M.D. Lefferts Hutton, M.D. 

PEDIATRIC ATTENDING PHYSICIAN 

Charles F. Collins, M.D. 

ASSISTANT PEDIATRIC ATTENDING PHYSICIAN 

Everett W. Gould, M.D. 

CONSULTING PHYSICIANS 

Charles W. Packard, M.D. Francis Delafield, M.D. 

Henry F. Walker, M.D. Beverly Robinson, M.D. 

Francis P. Kinnicutt, M.D. 

ATTENDING SURGEONS 

Robert Abbe, M.D. Charles L. Gibson, M.D. 

ASSOCIATE ATTENDING SURGEONS 

Henry Hamilton M. Lyle, M.D. Walton Martin, M.D. 

ASSISTANT ATTENDING SURGEONS 

W. S. Schley, M.D. John Douglas, M.D. 

Nathan W. Green, M.D. 

CONSULTING SURGEONS 

L. Bolton Bangs, M.D. Charles McBurney, M.D. 

Joseph A. Blake, M.D. Francis W. Murray, M.D. 

B. Farquhar Curtis, M.D. 

ATTENDING ORTHOPEDIC SURGEON CONSULTING ORTHOPEDIC SURGEON 

T. Halsted Myers, M.D. Newton M. Shaffer, M.D. 

CONSULTING GYNECOLOGIST CONSULTING NEUROLOGIST 

William M. Polk, M.D. Pearce Bailey, M.D. 

viii 



CONSULTING OPHTHALMOLOGIST 

Colman W. Cutler, M.D. 

ASSISTANT OPHTHALMOLOGIST 

Alfred Wiener, M.D. 

CONSULTING OTOLOGIST 

E. B. Dench, M.D. 

CONSULTING DERMATOLOGIST 

George T. Elliot, M.D. 



CONSULTING LARYNGOLOGIST 

D. Bryson Delavan, M.D. 

EXAMINING PHYSICIAN 

William S. Thomas, M.D. 

INSTRUCTOR IN ANESTHETICS 

H. Clifton Luke, M.D. 

CYSTOSCOPIST 

Harry G. Bugbee, M.D. 



PATHOLOGICAL DEPARTMENT 



DIRECTOR 

Francis C. Wood, M.D. 

CONSULTING PATHOLOGIST 

T. Mitchell Prudden, M.D. 

BACTERIOLOGIST CLINICAL PATHOLOGIST 

J. Gardner Hopkins, M.D. Karl M. Vogel, M.D. 

RESIDENT PATHOLOGIST ASSISTANT 

Charles H. Bailey, M.D. George C. Freeborn, M.D. 

ASSISTANTS IN CHEMISTRY 

N. B. Foster, M.D. E. C. Kendall, Ph.D. 



OFFICERS AND STANDING COMMITTEES OF THE 
MEDICAL BOARD FOR 1911 



OFFICERS 



PRESIDENT VICE-PRESIDENT 

B. Farquhar Curtis, M.D. Robert Abbe, M.D. 

SECRETARY 

Henry H. M. Lyle, M.D. 

COMMITTEE ON EXAMINATION OP CANDIDATES 
FOR THE HOUSE STAFF 

Robert Abbe, M.D. Austin W. Hollis, M.D. 

COMMITTEE ON EXAMINATION OF PUPIL NURSES 
EN SURGICAL SURJECTS IN MEDICAL SUBJECTS 

Charles L. Gibson, M.D. Samuel W. Lambert, M.D. 

Henry H. M. Lyle, M.D. Henry S. Patterson, M.D. 

IN MEDICINES 

William V. Byard, Apothecary. 



OUT-PATIENT DEPARTMENT 



PHYSICIAN IN CHIEF TO 
MEDICAL DIVISION 

Austin W. Hollis, M.D. 

ASSISTANTS 

W. C. Calhoun, M.D. 
Everett W. Gould, M.D. 
J. Preston Miller, M.D. 
Henry C. Williamson, M.D. 
Thomas Flynn, M.D. 
H. Merriman, M.D. 
A. Vander Veer, M.D. 



SURGEON IN CHIEF TO 
SURGICAL DIVISION 

William S. Thomas, M.D. 

ASSISTANTS 

Winfield Seott Schley. M.D. 
T. A. Kenyon, M.D 
F. 0. Virgin, M.D. 
H. E. Plummer, M.D. 
R. F. Longacre, M.D. 
J. Preston Miller, M.D. 
Frank C. Keil, M.D. 
Lefferts Hutton, M.D. 
A. L. Malabre, M.D. 
Otto H. Leber, M.D. 

SURGEON IN CHIEF TO OPHTHALMIC DIVISION 

Colman W. Cutler, M.D. 

ASSISTANT 

Alfred Wiener, M.D. 

SURGEON IN CHIEF TO GYNECOLOGICAL DIVISION 

John V. D. Young, M.D. 

ASSISTANTS 

F. 0. Virgin, M.D. H. E. Gardinor, M.D. 

Henry Christie Williamson, M.D. 

SURGEON IN CHIEF TO OTOLOGIC AL DIVISION 

E. B. Dench, M.D. 

ASSISTANTS 

F. T. Hopkins, M.D. Chas. E. Perkins, M.D. 

Abbott T. Hutchinson, M.D. Wesley C. Bowers, M.D. 

SURGEON IN CHIEF TO ORTHOPEDIC DIVISION 

T. Halsted Myers, M.D. 

ASSISTANTS 

Deas Murphy, M.D. H. D. Urquhart, M.D. 



List of Contents 



Managers of St. Luke's Hospital Hi 

Standing Committees of Board of Managers iv 

House Officers v 

House Staff vi 

Medical Staff viii 

Pathological Department ix 

Officers and Standing Committees of the Medical Board ix 

Out-Patient Department x 

Surgical Service Statistics for 1911 3 

Surgical Operations Performed in 1911 16 

Esophageal Strictures. By Robert Abbe, M.D 19 

Papilloma of the Vocal Cords. By Robert Abbe, M.D 22 

Rupture of the Kidney in Children. By Charles L. Gibson, M.D 25 

The Surgical Treatment of Colitis. By Charles L. Gibson, M.D 33 

Fecal Concretion in the Fallopian Tube. By Walton Martin, M.D 37 

Extensive Epithelioma of the Cheek with Secondary Involvement of the 

Genial Glands. By H. H. M. Lyle, M.D 39 

The Bottle Operation for Hydrocele of the Tunica Vaginalis: Ten cases. 

Three failures. By H. H. M. Lyle, M.D 42 

Intradural Section of the Sixth, Seventh, Eighth and First Dorsal Posterior 

Nerve Roots for Intractable Brachial Neuralgia : Failure to relieve the 

Pain. Later Section of the Corresponding Anterior Roots with no Relief. 

By H. H. M. Lyle, M.D 44 

Gumma of the Liver as a Sequel to Yaws. By H. H. M. Lyle. M.D 46 

Chronic Perisigmoiditis with Partial Volvulus. By H. H. M. Lyle, M.D. ... 48 
Perforation of a Simple Ulcer of the Colon : Operation. By H. H. M. Lyle, 

M.D 49 

A Series of Cases of Surgery of the Small Intestine. By W. Scott Schley, 

M.D 52 

Simplified Equipment and Management for the Operating Room. By W. 

Scott Schley, M.D 70 

Extrusion of Medullary Bone Splint. By W. Scott Schley, M.D 76 

Two Cases of Stone in the Ureter. By W. Scott Schley, M.D 78 

Tuberculous Peritonitis Simulating Recurring Attacks of Appendicitis. By 

W. Scott Schley, M.D 81 

The Gatch Bed in Surgical Work. By W. Scott Schley, M.D 83 

Subphrenic Abscess Complicating Appendicitis. By John Douglas, M.D 85 

Five Cases of Esophageal Obstruction from Three Different Causes. By 

Nathan W. Green, M.D 90 

Three Cases of Ileo-Colic Intussusception with Reduction and Anchorage 

by means of the Appendix : Two Recoveries. By Nathan W. Green, M.D. 95 
Mesenteric Thrombosis with Resection of Six Feet of Small Intestine: 

Recovery. By Nathan W. Green, M.D 98 

Papilloma of the Bladder Treated by Excision : Recurrence Treated with 

Radium and the High Frequency Current. By Henry G. Bugbee, M.D. . .101 

Bilateral Stricture of the Ureters. By Henry G. Bugbee, M.D 106 

Medical Service Statistics for 1911 Ill 

xi 



xii LIST OF CONTENTS 

Report of Cases of Hodgkin's Disease. By Austin W. Hollis, M.D., Otto 

H. Leber, M.D., and F. C. Wood, M.D 123 

A Case of Thrombosis of the Vertebral Artery. By Henry S. Patterson, 

M.D 133 

Report of a Case of Acute Endocarditis with Influx of all the Chorda? 

Tendinese of the Anterior Curtain of the Mitral Valves. By Lewis F. 

Frissell, M.D 135 

A Report of Two Unusual Cases of Sepsis. By Lewis F. Frissell, M.D 153 

The Dilatation Test for Chronic Appendicitis. By W. A. Bastedo, M.D 159 

The Vaccine Treatment of Typhoid Fever. By Austin W. Hollis, M.D. and 

Norman E. Ditman, M.D 164 

A Case of Paget's Disease. By Karl M. Vogel, M.D 168 

The Purin Content of Foodstuffs. By Karl M. Vogel, M.D 175 

Acute Bichloride of Mercury Poisoning: A Report of Two Cases with 

Recovery. By Lefferts Hutton, M.D 177 

A Case of Latent Dissecting Aneurism of the Aorta and Ruptured Sacciform 

Aneurism. By Lefferts Hutton, M.D. and J. Gardner Hopkins, M.D 180 

Report of a Case of Chronic Ulcerative Colitis, with Signa and Symptoms 

of Addison's Disease. By Edward N. Packard, M.D 188 

Pneumococcus Septicemia. By A. E. Neergaard, M.D 192 

Children's Service Statistics for 1911 197 

Orthopedic Service Statistics for 1911 203 

An Operation for Securing Motion in Ankylosis of the Elbow designed to 

prevent the Subsequent Occurrence of Flail Joint. By T. Halsted Myers, 

M.D 205 

The Radical Operation with the Application of the Primary Skin-Graft, for 

The Relief of Chronic Middle-Ear Suppuration. With Report of Cases. 

By Edward Bradford Dench, M.D 211 

A New Era in Medicine in New York. By F. C. Wood, M.D 217 

Selecting Lenses for Photo-Micrography. By F. C. Wood, M.D 227 

Case of Incomplete Rupture of the Heart due to Coronary Hemorrhage. 

By J. Gardner Hopkins, M.D 242 

Report of the Wassermann Reactions done by the Pathological Department 

during the Year 1911. By C. H. Bailey, M.D 246 

Complement in Human Serum. By C. H. Bailey, M.D 255 

Effects on Titrations of Inequality of Sensitization of Corpuscles. By C. 

H. Bailey, M.D 258 

The Determination of Copper: A Modification of the Iodide Method. By 

E. C. Kendall, Ph.D 265 

The Determination of Iodine in the Presence of other Halogens and Organic 

Matter. By E, C. Kendall, Ph.D 272 

A New Method for the Determination of the Reducing Sugars. By E. C. 

Kendall, Ph.D 288 

Atropin Therapy in Diabetes Mellitus. By Herman O. Mosenthal, M.D 316 

Anatomical Study of a Thoracopagus. By J. R. Pawling, M.D 320 

Report of the Pathological Department of St. Luke's Hospital for the Year 

1911. By F. C. Wood, M.D 324 

Plans of the Roentgen Ray Laboratory, Under Construction on the Third 

Floor of the Travers Pavilion, St. Luke's Hospital. By Leon Theodore 

Le Wald, M.D 339 

Report of a Case of Dilatation of the Stomach. Medical Treatment. 

Recorded by Means of the X-ray. By Leon Theodore Le Wald, M.D. . . .340 
Practical Notes from the Surgical Division of the Out-Patient Department 

By William S. Thomas, M.D 345 

Possible Causes of Failure Following the Use of Bacterial Vaccines and 

Antisera. By H. E. Plummer, M.D 349 



Surgical Service 



SURGICAL STATISTICS FOR 1911 



ALIMENTARY SYSTEM 

INTESTINES 



DO 




a 




o 












03 


-o 


n 






u 


a 


3 


o 


O 



Colitia 

Colitis, mucous adhesions 

Colitis (ulcerative), hemorrhages. 

Diverticulitis 

Duodenal ulcer 

Duodenal ulcer, peritonitis 

Duodenal ulcer, volvulus 

Enteritis, gastro-enteritis 

Enteroptosis 

Ileus 

Ileus, band 

Ileus, intestinal adhesions 

Intestinal indigestion 

Intussusception 

Perisigmoiditis 

Vicious circle 



Hernia (femoral) 

Hernia (femoral, incarcerated), ing. hernia 

Hernia (femoral, strangulated) ) 

Hernia ( inguinal ) 

Hernia (inguinal sliding) 

Hernia (inguinal strangulated) 

Hernia (inguinal), oedema of lungs, broncho-pneu 

Hernia (umbilical) 

Hernia ( ventral ) 

Hernia, (ventral strangulated) 

Hernia (ventral), ileus, abscess of abdominal wall 

general peritonitis 

Hernia (umbilical), abscess of scrotum, croup , 

Hernia (inguinal), pleurisy with effusion 

Hernia (inguinal), lobar pneumonia , 

Hernia (inguinal), phimosis, undescended testis , 

Hernia ( omental ) 



LIVER 



Abscess of liver 

Abscess of liver, diffuse peritonitis 

Abscess of liver, miliary tbc 

Cirrhosis of liver, oedema of lungs 

Cirrhosis of liver, endocarditis, ascites, oedema of lungs 
Hepatitis (interstitial), displacem't of transverse colon 
Jaundice (obstructive) 



BILE PASSAGES 



Cholecystitis 

Cholecystitis (gangrenous), peritonitis. 

Cholecystitis, toxic insanity 

Cholecystitis (suppurative) 

Cholelithiasis 

Cholelithiasis with adhesions 

Cholelithiasis, cholangitis 



29 



1 
1 
128 
1 
4 
1 
7 
23 
3 

1 
1 
1 
1 
1 
1 



184 



18 



2 

143 
1 
3 



193 



1 
2 
1 
1 
3 
3 
1 
1 
3 
7 
4 
1 
2 
5 
1 
1 

37 



10 
1 
2 
154 
1 
4 
1 
7 

25 
3 

1 
1 

1 

1 
1 
1 

214 



5 
1 
1 
1 
26 
1 
1 



ST. LUKE'S HOSPITAL REPORTS 



ALIMENTARY SYSTEM — Continued 



Bile Passages — Cont. 

Cholelithiasis, cholecystitis 

Cholelithiasis, carcinoma of pancreas. 

Cholelithiasis, pleuro-pneumonia 

Empyema of gall bladder 

Hydrops, stone in common duct 



MOUTH, GUMS AND TEETH 

Alveolar abscess 

Painful alveolar process , 

Suppurating root of tooth 



OESOPHAGUS 



Stricture of oesophagus 

Stricture of oesophagus, gastric adhesions, gangrene 
of lung 



PANCREAS 



Pancreatitis (acute), cholecystitis 

Pancreatitis (hemorrhagic), delirium tremens. 



PERITONEUM 



Abscess of peritoneum 

Adhesions 

Peritonitis, cause unknown. 



PHARYNX, TONSILS AND NASOPHARYNX 



Abscess (peritonsillar) 

Adenoids 

Hypertrophy of tonsils 

Hyp. tonsils, facial paralysis. 

Hyp. tonsils, adenoids 

Tonsillar hemorrhage 

Tonsillitis (follicular) 



Abscess ( anal ) 

Atresia of anus 

Fissure in ano 

Fistula In ano 

Fistula in ano, pul. tbc 

Fistula (fecal) 

Fistula (fecal), old appendicitis, peritonitis. 

Hemorrhoids 

Hemorrhoids, with enlarged glands, neuritis. 

Ischio-rectal abscess 

Ischio-rectal abscess, sub-ac. nephritis 

Proctitis, ischio-rectal abscess 

Prolapse of anus 

Prolapse of rectum, erysipelas 

Stricture of rectum 



STOMACH 



Gastritis (atrophic) cirrhosis of liver 

Gastritis (chr.) 

Gastritis (chr.), morphinism, neurasthenia. 

Gastritis (chr.), perforation 

Indigestion 

Ptosis, dilatation 



47 



10 



139 



123 



37 



140 



54 



10 
1 
2 

1 

"i 

106 



1 
1 

1 

20 



10 
1 
2 
3 
1 

53 



3 

7 
2 

12 



6 
10 
25 

1 
97 

5 

2 

146 



1 
1 
7 

29 
2 
7 
1 

63 
1 

13 
1 
2 
3 
1 
2 

134 



SURGICAL STATISTICS FOR 1911 



ALIMENTARY SYSTEM— Continued 


d 

O 


d 


a 

a 


d 
P 


13 

0) 

s 


"3 



Stomach — Cont. 
Pyloric obstruction 


3 
2 
5 
1 


2 
1 
3 
1 


1 
1 
2 

9 

3 

2 

1 






3 




2 




1 


1 
1 


7 




2 






VERMIFORM APPENDIX 

Appendicitis (acute) 


14 

65 

30 

30 

1 

1 

1 


11 

61 
24 

28 


3 


4 

1 
5 

1 
1 
1 


27 
65 




31 




30 


Appendicitis (ac. ), peritoneal abs., pulmonary embolus 


1 










1 


Appendicitis (ac. catarrhal) 


1 
3 
190 
1 
3 
7 
4 
1 
16 
1 
1 

1 
1 
1 
1 

1 






1 


Appendicitis (chronic catarrhal) 








3 


Appendicitis (chr.) 


191 


7 


5 

1 


1 


203 




2 




3 
7 
6 
1 
16 
1 
1 

1 
1 
1 

1 

1 


3 










7 








2 

1 


6 




1 




2 




17 








1 


Appendicitis (sub-acute), ac. pneumonia 








1 


Appendicitis (sub-acute), thrombosed veins of thigh, 








1 


Appendicitis (relapsing), renal calculus 








1 


Appendicitis (relapsing), suppurative pneumonia 








1 










1 










1 






6 






CARDIOVASCULAR SYSTEM 

BLOOD 


359 


346 
1 


14 

1 

1 
1 


13 


379 

2 


Anemia (pernicious.) 




1 




1 




1 






ARTERIES 


1 
1 


1 


3 
1 




1 


4 
1 




1 










1 
1 


1 










1 




1 


1 
1 


1 


2 




1 




2 


1 


2 


1 


2 






VEINS 


4 


2 
1 


3 


2 


9 
1 






1 
1 






1 








1 




1 

1 

20 


1 

"20 

1 


1 




1 
3 


3 




1 




26 
1 














HEART 


22 


23 


6 


3 


1 
1 
1 


32 
1 












1 




1 








1 














1 


.... 






3 


3 



ST. LUKE'S HOSPITAL REPORTS 



CARDIOVASCULAR SYSTEM— Continued 


a 

O 





S 


Ui 


5 


"3 


EH 


LYMPH GLANDS 


5 
16 

1 
6 

1 


6 
10 

1 
6 
1 
1 


' ' 6 


1 




7 




16 


Lymphadenitis (femoral) 


1 




3 






9 




1 










1 








1 






CONNECTIVE TISSUE 


29 
1 


25 

' 'i 
l 
l 

2 
1 

1 
7 
6 

2 

3 
9 
4 

1 
1 
2 


9 
1 




35 

1 




1 




1 
1 
2 
1 
1 
8 
8 
3 
1 
3 
1 
12 
4 
1 
1 
2 








1 










1 










2 


Abscess of popliteal space 








1 










1 




2 
3 
3 






9 




9 


Cellulitis of arm (gangrenous) 


3 


Cellulitis of broad ligament 


1 




2 
7 
1 




i 
i 


3 




6 


Cellulitis of hand 


16 


Cellulitis of leg 






5 


Cellulitis of parotid region 


1 


Cellulitis of penis 








1 


Cellulitis of scalp 








2 


Cellulitis of scalp, necrosis of maxilla 


1 






1 








1 




1 


Hematoma of chest wall 


1 

1 


1 

2 




1 










2 


Hematoma of scrotum, hydrocele 




1 

3 




1 


Perineal inflammation following urethral stricture... 


1 
3 


' i 


1 


1 
4 






DUCTLESS GLANDS 
Addison's disease 


56 


47 


21 

1 
3 


5 


2 


75 
1 


Goitre (simple) 


8 
3 
1 
2 

1 


6 

3 
1 

' i 






9 




3 


Hyperthyroidism 








1 




1 


1 




2 


Parotiditis (acute) 


1 




5 


1 






MUSCULAR SYSTEM 
Bursitis of popliteal space 


15 
1 


11 

1 
1 


17 
1 


Myosotis 












1 


1 




2 
1 

' '2 


1 






NERVOUS SYSTEM 

BRAIN 

Abscess of brain 


2 

2 

1 


2 


1 


2 
2 


Cyst of ventricle 








1 








1 

1 

1 
1 

1 


1 








3 


5 










DISEASES OF THE MIND 


3 




3 


5 

.... 


9 
1 






6 


2) 




NERVES 


7| 


1 
9 



SURGICAL STATISTICS FOR 1911 



NERVOUS SYSTEM— Continued 



Nerves — Cont. 

Neuralgia (trifacial), paralysis, eczema. 

Neuritis (brachial) 

Neuritis (peripheral) 

Neuritis (retro-bulbar) 



NERVOUS DISEASES OF UNKNOWN ORIGIN 



Hysteria 

Nervous prostration 

Neurasthenia (traumatic) 

Spasmodic torticollis 

Zoster, gangrenous hystericosus of forearm. 



SPINAL CORD 



Locomotor ataxia 

Syringomyelia, paraplegia. 
Tabes dorsalis 



OSSEOUS SYSTEM 



Athetosis of arm 

Coccygodynia 

Hypertrophy of turbinate bone 

Necrosis of vertebrae 

Necrosis of maxilla 

Necrosis of femur. Pott's Disease 

Osteitis (rarefying) 

Osteomyelitis of femur 

Osteomyelitis of forehead 

Osteomyelitis of humerus 

Osteomyelitis of maxilla 

Osteomyelitis of metacarpal bones of hand. 
Osteomyelitis of metatarsal bones of foot . . . 

Osteomyelitis of tibia 

Periosteitis of phalanx of hand 

Periosteitis of femur 

Periosteitis of tibia 

Periosteal abscess of maxilla 

Rickets 

Sequestrum of maxilla 



JOINTS 



Ankylosis of ankle 

Ankylosis of hip and knee 

Arthritis (chr.) of knee 

Arthritis (suppurative) of ankle 

Bunions 

Hypertrophy of int. ligament of knee. . 
Hypertrophy of synovial folds of knee. 

Osteo-arthritis of hip 

Osteo-arthritis of knee and vertebra?.. 
Synovitis of knee 



REPRODUCTIVE SYSTEM— FEMALE 

OVARY 

Atrophy of ovary 

Abscess (tubo-ovarian. ) 

Cystic ovary 

Cystic ovary (multilocular) 

Cystic ovary, pregnancy 

Oophoritis 

Oophoritis (atrophic) 



27 



10 



22 



1 
4 
39 
2 
1 
9 
1 



1 

1 
2 
2 

15 



11 



1 
2 
1 
1 
1 
1 
1 
6 
2 
1 
2 
2 
3 
2 
3 
1 
2 
1 
1 
1 

35 



2 

1 
2 

1 
1 

1 
1 
1 
1 
3 

14 



1 
4 

40 
2 
1 

10 
1 



ST. LUKE'S HOSPITAL REPORTS 



REPRODUCTIVE SYSTEM— FEMALE— Continued 



Ovary— Cont. 



Parovarian cyst. . . 
Prolapse of ovary. 



UTERINE TUBES 

Hematosalpinx 

Hematosalpinx with twisted pedicle, pregnancy 

Hydrosalpinx 

Pyosalpinx 

Pyosalpinx with abscess 

Pyosalpinx with abscess, thrombosis of broad liga- 
ment and iliac veins 

Salpingitis (acute) 

Salpingitis (chronic) 

Salpingitis (chr.) post-op. shock, peritonitis 

Salpingitis (chr.), peritonitis 

Salpingitis (perforative) 

Salpingitis with pelvic abscess 

Pyosalpinx, paralytic ileus, peritonitis 

Salpingo-oophoritis 



UTERUS 



Abscess of broad ligament 

Anteflexion 

Cyst (intra-ligamentous) 

Dysmenorrhea 

Endocervicitis 

Endometritis (chr.) 

Endometritis (glandular) 

Endometritis (hypertrophic) 

Erosion of cervix 

Menopause (artificial) 

Metrorrhagia 

Prolapse of uterus 

Prolapse of uterus, rectocele, cystocele 

Prolapse of uterus, laceration of cervix and perineum 

Retroversion 

Retroversion, pregnancy 

Retroversion with adhesions 



PREGNANCY, ETC. 



Abortion (complete) 

Abortion (incomplete) 

Abortion (threatened) 

Abortion (incomplete), pelvic abscess. 

Ectopic gestation 

Ectopic gestation (ruptured) 

Lithopedion 

Pelvic abscess 

Pelvic abscess, pyometra 

Pelvic abscess, ileus 

Pregnancy 

Retained placenta 

Toxemia of pregnancy 



Atresia of vagina 

Prolapse ant. vaginal wall. 
Prolapse post, vaginal wall 
Vaginitis 



Abscess (vulvo-vaginal). 



CO 



26 



112 



180 



79 



20 



60 



3 

1 

3 

23 

1 



6 
45 



18 
104 



1 

7 
4 
4 
1 
74 
1 
1 



1 

2 
18 
1 
2 
53 
1 
1 



172 



4 
19 



1 
12 



1 
14 



1 
14 

1 



79 



1 

13 

5 

1 



20 



3 
11 



1 
19 



13 



62 



3 

1 

3 

29 

2 

1 
9 

62 

1 
2 
2 
1 
1 
19 

136 



1 

10 
4 
4 
1 

86 
1 
1 
1 
1 
2 

22 
1 
2 

53 
1 
1 

792 



4 

22 
5 
1 

12 
8 
1 

16 
1 
1 
5 

16 
2 

94 



1 

13 

5 

1 

20 



SURGICAL STATISTICS FOR 1911 



REPRODUCTIVE SYSTEM— FEMALE— Continued 


O 


d 


a 


a* 
P 


•a 

s 


"3 
© 


Vulva — Cont. 
Abscess (Bartholin's gland) 


1 
1 


l 
l 








1 










1 












REPRODUCTIVE SYSTEM— MALE 

MALE URETHRA 


3 

1 

10 

1 


4 

1 
9 
1 


i 






5 

1 


Stricture of urethra 


3 


1 


1 


14 


Stricture of urethra, calculus, extravasation of urine 


1 












PENIS 


12 

1 

15 

8 

24 
4 


11 

2 
15 

8 


3 


1 


1 


16 
2 










15 










8 














25 
2 








25 


PROSTATE 


1 
1 
2 




1 


4 




1 




8 

1 


4 
1 

7 

9 
20 




4 


10 




1 












SPERMATIC CORD 


13 

9 
20 


4 




5 


16 
9 




1 


2 




23 




TESTICLE 


29 

1 


29 
1 


1 


2 




32 
1 














1 

3 

1 
4 
1 


1 

3 
1 
2 








| 1 


MAMMARY GLAND 








3 
1 












2 

1 


1 

1 

1 

1 








2 






RESPIRATORY SYSTEM 

LARYNX 


9 


6 


3 




10 

1 












LUNGS 






1 

1 




1 
1 








PLEURA 




1 


1 
1 


1 

1 

1 

16 

1 








1 
5 




13 

1 


10 


Pleurisy (supp.), catarrhal croup, ac. bronchitis 






6 

1 

1 
1 






NASAL CAVITY 


14 


10 


1 
1 


2 


19 

1 

1 

13 










11 


11 



10 



ST. LUKES HOSPITAL REPORTS 



RESPIRATORY SYSTEM— Continued 



Nasal Cavity — Cont. 



Epistaxis 

Frontal sinusitis. 



SENSE ORGANS 



ORGAN OF HEARING 



Mastoiditis 

Mastoiditis, meningitis, otitis media 

Mastoiditis, thrombosis of lateral sinus 

Mastoiditis (suppurative), catarrhal jaundice, lobar 

pneumonia, septic arthritis of elbow 

Otitis media 

Otitis media (purulent) 



ORGAN OF VISION 



Cataract 

Chalazion 

Conjunctivitis 

Exotropion 

Glaucoma 

Iritis, dacryocystitis 

Ophthalmitis 

Panophthalmitis 

Rupture of cornea ' 

Strabismus 

Traumatic conjunctival hemorrhage. 



TEGUMENTARY SYSTEM 



Carbuncle of lip 

Carbuncle of neck 

Cicatrix ( painful ) 

Furunculosis 

Ingrowing toe-nail 

Pilonidal cyst 

Purpura hemorrhagica 

Sebaceous cyst of head. . . . 

Ulcer of foot 

Ulcer of neck 

Ulcer (perforative) of foot. 
Ulcers (varicose) of leg. . . . 



URINARY SYSTEM 



Abscess of kidney 

Hydronephrosis 

Nephritis (chr. interstitial ) 

Nephritis (chr. interstitial), ascites. 

Nephrolithiasis 

Nephroptosis 

Movable kidney 

Movable kidney, pyelonephritis 

Perinephritic cyst 

Pyelitis 

Pyelonephritis 

Pyonephrosis, pregnancy 

Renal colic 

Renal colic, hemorrhagic cystitis. . . . 
Traumatic nephritis 



URINARY BLADDER 



11 



18 



19 



23 



Calculus in bladder. . . . 
Calculus, tabes dorsalis. 



24 



id 



14 



2-A 



16 



12 



1 

' i 

15 



18 



10 

1 
1 

1 
8 

1 

22 



11 
1 

1 
1 
5 
2 

1 
1 
1 
1 

1 

26 



1 
4 
2 
2 

1 
2 
1 
3 
1 
1 
3 
7 

28 



1 
4 
3 
2 
11 
5 
4 
1 
1 
2 
3 
1 
2 
1 
1 

42 



SURGICAL STATISTICS FOR 1911 



11 



URINARY SYSTEM— Continued 


o 


c 


a 

3 


a 
P 


01 

5 


"3 
o 


Urinary Bladder — Cont. 
Cystitis (hemorrhagic) 






1 
1 
1 


1 


2 


1 


Cystitis, cystocele 


l 


. „ 


1 


Cystitis, tumor of bladder 


2 






1 




l 
l 


1 
1 


1 


4 


Ulcer of bladder 


1 




6 


2 

1 
1 

2 
1 






DISEASES DUE TO ANIMAL PARASITES 


6 


4 


3 


15 
1 










1 












CONGENITAL MALFORMATIONS 
Branchial genetic cyst 


1 


1 


2 

1 

1 


Contraction of foot 


1 




2 
1 
4 


2 
1 




5 
1 
2 
4 
2 
2 


2 
1 


6 




1 


Hydrocephalus 






2 


2 




3 
2 
2 


1 




4 




2 










2 






1 


2 




DEFORMITIES 


18 
1 


10 
1 


9 

1 
1 
1 
2 
1 


22 

2 




1 




2 
3 
1 


1 
1 


2 




1 




3 




1 




1 




2 


1 


1 


2 






LOCAL INJURIES 


9 


4 


7 
1 


1 




12 
1 






1 
1 
1 
1 
1 
2 






1 












1 




1 


2 




1 


4 




1 






4 

1 
1 
1 
















3 






3 








1 






1 


1 






1 






1 




1 
1 
4 
1 
2 
1 
1 
1 
1 
1 
1 
2 
2 
1 
1 


1 

2 
2 

1 
1 
1 
1 
1 
1 
2 
2 
1 
1 
1 
3 






1 




1 






1 




4 




1 






3 

2 












1 










1 










1 








1 










1 








1 








2 


1 






3 




1 








1 


1 

2 

1 


2 


1 

1 


2 




2 
1 


8 




1 




1 






3 


i 




4 



12 



ST. LUKE'S HOSPITAL REPORTS 



LOCAL INJURIES — Continued 



Local Injuries — Cont. 



Fracture of fibula (Potts') 

Fracture of humerus 

Fracture of jaw 

Fracture of neck of femur, pneumonia. 

Fracture of os calcis 

Fracture of olecranon 

Fracture of patella 

Fracture of phalanx 

Fracture of radius 

Fracture of radius (Colles') 

Fracture of radius and ulna 

Fracture of ribs 

Fracture of skull 

Fracture of tibia 

Fracture of tibia and fibula 

Fracture of tibia (ununited) 

Fracture of vertebrae 

Fracture of vertebrae, alcoholism 

Gangrene of foot 

Gangrene (diabetic) of foot 

Gangrene of foot, arterio-sclerosis 

Gangrene of foot, nephritis 

Gangrene (dry) of foot, nephritis 

Gangrene (wet) of foot 

Heat prostration 

Laceration of cervix uteri 

Laceration of perineum 

Perforation of ileum 

Rupture erector spinal muscle 

Rupture of ligament of knee 

Sinus of abdominal wall 

Sinus of leg 

Sinus of neck 

Sinus of sacro-coccygeal region 

Sinus of thigh 

Sinus, perirectal 

Sprain of ankle 

Wound (gunshot) of face 

Wound (incised) of neck 

Wound (lacerated) of neck 

Wound (lacerated) of hand 

Wound (lacerated) of scalp 

Wound (lacerated) of scrotum 

Wound (incised) of abdomen 



DISEASES DUE TO MICRO-ORGANISMS 



Erysipelas 

Gonococcus epididymitis 

Gonococcus salpingitis 

Gonococcus uterus and tubes 

Gonococcus urethritis 

Malaria 

Pertussis 

Rheumatism (ac. articular) 

Scarlet fever 

Syphilis (primary) 

Syphilis (secondary) 

Syphilis (tertiary) 

Syph. adenitis, axillary and inguinal. 

Syph. gumma of scalp 

Syph. gumma of liver 

Syph. osteitis of femur 

Syph. osteitis of tibia 

Syph. fistula in ano 

Tbc. abscess of shoulder 

Tbc. of bladder 

Tbc. of bladder, nephritis 

Tbc. of elbow 

Tbc. of eyelid 

Tbc. of epididymis, orchitis 



154 



151 



70 



1 
15 



SURGICAL STATISTICS FOR 1911 



13 



DISEASES DUE TO MICRO-ORGANISMS— Continued 



I O 



Diseases Due to Micro-Organisms — Cont. 



Tbc. of finger 

Tbc. of foot 

Tbc. of glands of neck 

Tbc. of hand 

Tbc. of kidney 

Tbc. of knee 

Tbc. of lungs 

Tbc. of peritoneum 

Tbc. of prostate and bladder 

Tbc. of rib 

Tbc. of spine 

Tbc. of testicle 

Tbc. of uterine tubes, pulmonary tbc 

Tbc. of uterus and broad ligament 

Tbc. costal cartilage pectoralis major 

Tbc. fecal fistula 

Tbc. lumbar abscess 

Tbc. ovarian cyst 

Tbc. peritonitis, thrombosis saphenous vein, prolapse 

of vagina 

Tbc. keratitis 

Tbc. salpingitis, peritonitis, fecal fistula 



LOCAL INFECTIONS 



Infection of hand and arm 

Infection of herniotomy wound. 
Stitch abscess 



NEOPLASMS 



Adenoma of breast 

Adenoma of endometrium 

Adeno-carcinoma of colon 

Adeno-carcinoma of rectum 

Adeno-carcinoma of uterus 

Adeno-fibroma of breast 

Adeno-fibroma of uterus 

Angioma of neck 

Carcinoma of abdominal wall 

Carcinoma of antrum 

Carcinoma of bile duct 

Carcinoma of bladder 

Carcinoma of breast 

Carcinoma of cervix uteri 

Carcinoma of chest wall 

Carcinoma of face and cheek 

Carcinoma of glands (inguinal) 

Carcinoma of intestines 

Carcinoma of liver 

Carcinoma of lungs and pleura 

Carcinoma of neck 

Carcinoma of oesophagus 

Carcinoma of orbit 

Carcinoma of ovary 

Carcinoma of parotid gland 

Carcinoma of pancreas 

Carcinoma of rectum 

Carcinoma of rectum, fibroma uteri, pulmonary throm- 
bosis 

Carcinoma of tonsil 

Carcinoma of stomach 

Carcinoma of tongue 

Carcinoma of thorax, ribs, axillary glands, fracture of 
femur 

Carcinoma of uterus 

Carcinoma of vagina 

Carcinoma of vulva 

Cyst-adenoma of breast 

Cyst-adenoma of ovary 



82 



1 
31 



62 



3 
21 

1 
1 
3 

1 
1 



1 

45 

1 



13 

1 



1 
17 

1 



1 
1 
38 
1 
6 
6 
6 
3 
1 
3 
1 
2 
1 
2 
1 
1 
1 
1 

1 

1 

1 

122 



4 
1 
2 
3 
1 
5 
1 
1 
2 
1 
2 
6 

44 
4 
1 
5 
1 

14 
1 
1 
7 
3 
2 
8 
2 
2 

11 

1 

2 

10 

1 

1 
10 

1 
1 

2 
3 



14 



ST. LUKE'S HOSPITAL REPORTS 



NEOPLASMS— Continued 



Neoplasms — Cont. 



Cyst-adenoma of neck 

Dermoid cyst of ovary 

Dermoid cyst of chest wall 

Epithelioma of face 

Epithelioma of forehead 

Epithelioma of neck 

Epithelioma of nose 

Epithelioma of lip 

Epithelioma of orbit 

Epithelioma of maxilla 

Epithelioma of tongue 

Epithelioma of tonsil 

Epithelioma of toe 

Epithelioma of vagina 

Epithelioma of vulva 

Epulis 

Exostosis of hard palate 

Exostosis of os calcis 

Fibromyoma of uterus 

Fibromyoma of uterus, pregnancy 

Fibroma of omentum 

Fibro-sarcoma of femur 

Glioma of ulna nerve 

Lipoma of abdominal wall 

Lipoma of buttock 

Lipoma of chest wall 

Lipoma of chest and arms 

Lipoma of neck 

Lipoma of shoulders 

Lipoma of thigh 

Lymphangioma of neck 

Lympho-sarcoma of neck 

Hemangioma of hand 

Myxo-sarcoma of thigh 

New growth of patella 

Neuro-fibroma-lipomata (multiple) 

Papilloma of bladder 

Papilloma of larynx 

Papilloma of toe 

Papilloma of ovary, pregnancy 

Polyp of rectum 

Polyp of uterus 

Sarcoma of bladder 

Sarcoma of abdominal wall 

Sarcoma of leg 

Sarcoma of maxilla 

Sarcoma of mediastinum, aneurysm of aorta. 

Sarcoma of testis 

Sarcoma of neck 

Sarcoma of sacrum 

Sarcoma of sheath of thigh muscle 

Sarcoma of tibia 

Tumor of abdomen 

Tumor of breast 

Tumor of face 

Tumor of intestines 

Tumor of neck 

Tumor of parotid 

Tumor of prostate 

Tumor of rectum 

Teratoma of abdomen 

Teratoma of testicle 



INTOXICATIONS 



Auto-intoxication 

Diabetes mellitus 

Diabetes, ulcers, nephritis. 

Gout 

Morphinism 



2G4 



1 
194 



79 

1 
1 
1 

i 

4 



40 



32 



SURGICAL STATISTICS FOR 1911 



MISCELLANEOUS 



Donor in transfusion 

Diagnosis not made 

For observation 

No pathological condition 



SUMMARY 



Alimentary System 

Cardiovascular System. . . 

Connective Tissue 

Ductless Glands 

Muscular System 

Nervous System 

Osseous System 

Reproductive System 

(Mammary Gland) 

Respiratory System 

Sense Organs 

Tegumentary System 

Urinary System 

Animal Parasites 

Congenital Malformations. 

Deformities 

Local Injuries 

Micro-organic Diseases. . . . 

Neoplasms 

Intoxications 

Miscellaneous 



Total 2189 2047 



919 
57 
56 
15 
2 
11 
35 

533 
9 
25 
37 
23 
30 



18 

9 

154 

89 
264 



872 

51 

47 

11 

2 

7 

16 

512 

6 

22 

25 

14 

27 



10 

4 

151 



194 

1 
7 



10 



75 

21 

21 

5 

1 

19 

28 

49 

3 

12 

20 

12 

21 



9 
7 
70 
46 
79 
4 
10 



512 



2 
' 9 

11 



37 
6 
5 

1 

"8 

3 

20 

1 

3 

2 

1 

3 

2 

1 

1 

15 

14 

40 

ii 

174 



2 

7 

3 

16 

28 



48 
5 
2 



5 

2 
18 

' 2 
1 
1 
6 



6 

2 

22 



122 2854 



OPERATIONS— 1911 



ALIMENTARY SYSTEM 

INTESTINES 



Cecostomy 

Colostomy 

Entero-eolostomy 

Entero-enterostomy . . . 

Enterostomy 

Enterorrhaphy 

Ileo-colostomy 

Ileo-colectomy 

Intestinal anastomosis. 

Jejunostomy 

Proctoscopy 

Resection of intestines. 



HERNIA 

Femoral hernia repair 8 

Inguinal hernia repair 107 

Omental hernia repair 2 

Umbilical hernia repair 8 

Ventral hernia repair 20 

LIVER AND BILE PASSAGES 

Cholecystenterostomy 2 

Cholecystectomy 17 

Cholecystostomy 12 

Cholecystotomy 8 

Choledochotomy 1 

Cholelithotomy 3 

Duodenorrhaphy 1 

Duodenostomy 1 

Incision for abscess of liver 1 



MOUTH, TONGUE AND TEETH 

Extraction of tooth 

Incision of alveolar abscess 

Partial glossectomy 



OESOPHAGUS 



Dilatation of oesophagus. 
CEsophagotomy 



PERITONEUM, OMENTUM AND RETHO-PERITO- 
NEAL TISSUES 

Celiotomy 4 

Closure of perforation 1 

Division of adhesions 16 

Exploratory celiotomy 35 

PHARYNX, TONSILS AND NASOPHARYNX 

Adenoidectomy 9 

Adenoidectomy and tonsillectomy 78 

Incision for peritonsillar abscess 3 

Tonsillectomy 18 

RECTUM, ANUS AND PERI-EECTAL TISSUES 

Clamp and cautery 36 

Dilatation of sphincter ani 9 

Excision of fistula in ano 2 

Excision of mucous membrane of rectum 4 

Incision of fistula in ano 21 

Incision of ischio-rectal abscess 7 

Incision of peri-rectal abscess 1 

Ligation of hemorrhoids 7 

Proctectomy 1 

Proctoscopy 2 

Dissection of fistulous tract 2 



STOMACH 

Gastrectomy (partial) 

Gastroenterostomy 

Gastropexy 



VERMIFORM APPENDIX 

Appendicectomy 219 

Appendicectomy with drain 69 

Appendicostomy 2 

Appendipexy l 

Drainage of appendicular abscess 4 

CARDIOVASCULAR SYYSTEM 

ARTERIES 

Ligation of artery 2 



VEINS 

Ligation of vein 8 

Phlebectomy 32 

LYMPH GLANDS 

Incision 4 

Lymphadenectomy 44 

Lymphadenectomy (tbc. cervical) 17 

CONNECTIVE TISSUE 

Excision of carbuncle 3 

Excision of scar 5 

Incision for abscess 40 

Incision for cellulitis 33 

Repair of fistula 6 

Repair of scar . . , 5 

Repair of sinus 5 

DUCTLESS GLANDS 

Excision of goitre 1 

Formation of fistula from parotid duct 1 

Incision of parotid duct 1 

Thyroidectomy 8 

MUSCULAR SYSTEM 

Excision of bursae 2 

Excision of ligaments 1 

Excision of semi-lunar cartilage of knee 1 

Myectomy l 

Tendon transplantation 3 

Tenoplasty 1 

Tenotomy 1 



NERVOUS SYSTEM 

BRAIN 



Decompression , 

Drainage of abscess 

Elevation of depressed fragments. 

Exploratory craniotomy 

Subdural drainage 



NERVES 



Neurectomy. 



SPINAL CORD 



Laminectomy. 



OSSEOUS SYSTEM 



Ostectomy 

Osteotomy 

Osteotomy with drain 

Reduction of fracture (closed) 
Reduction (opeb) of fracture. 

Resection of knee 

Resection of carpal bones 



JOINTS 



16 



Arthrectomy 

Arthrodesis 

Arthrotomy 

Excision of meniscus 

Excision of synovial folds. 
Removal of foreign body . . 



8 
12 

7 

1 
4 
1 
1 



OPERATIONS PERFORMED— 1911 



17 



REPRODUCTIVE SYSTEM 

OVARY 

Excision of cyst 5 

Incision for cyst 2 

Oophorectomy 37 

Plastic on ovary 3 

Shortening ligament of ovary 1 

UTERINE TUBE 

Salpingectomy 44 

Salpingectomy with drain 4 

Saipingo-oophorectomy 85 

UTERUS 

Amputation of cervix uteri 2 

Curettage 116 

Excision of intraligamentous cyst.... 2 

Hysterectomy (complete) 4 

Hysterectomy (partial) 4 

Hysterectomy (supravaginal) 64 

Hysteropexy (round ligament) 25 

Hysteropexy (ventral) 32 

Myomectomy 6 

Tracheoplasty 11 

Trachelorrhaphy 12 

VAGINA AND PELVIC FLOOR 

Colpoplasty 5 

Colporrhaphy 15 

Oolpotomy 21 

Excision of cyst 2 

Incision of cyst 1 

Perineoplasty 26 

Perineorrhaphy 24 

Plastic repair of abscess 1 

URETHRA 

Urethrotomy 9 

PENIS 

Circumcision 18 

Incision of scrotum for abscess 1 

Meatotomy 1 

PROSTATE 

Prostatectomy (perineal) 6 

Prostatectomy (suprapubic) 4 

TESTICLES 

Incision for orchitis 1 

Orchidectomy 4 

Transplantation of testicle 4 

SPERMATIC CORD 

Bottle operation for hydrocele 1 

Excision of hydrocele sac 6 

Eversion for hydrocele 1 

Inversion for hydrocele 1 

RESPIRATORY SYSTEM 

LARYNX, BRONCHI AND TRACHEA 

Tracheotomy 2 

LUNGS AND PLEURAE 

Costatectomy 14 

Decortication 1 

Thoracotomy 19 

Thoracostomy 3 

NASAL CAVITY 

Opening of lateral sinus 1 

Plugging of nares 1 

Submucous resection 9 



ORGAN OF HEARING 

Mastoidectomy (partial) 8 

Mastoidectomy (radical) 4 

Mastoidotomy 4 

Paracentesis 4 

ORGAN OF VISION 

Curettment for tbc. of eyelid 1 

Dilatation for cataract 1 

Discission of cataract 2 

Enucleation of eyeball 3 

Excision of cataract 4 

Excision of eyeball 2 

Needling for cataract 1 

Removal of lens 1 

TEGUMENTARY SYSTEM 

Excision of carbuncle 1 

Excision of sebaceous cyst 3 

Incision for furuncle 2 

Onychectomy 1 

Removal of foreign body 2 

Skin graft 7 

URINARY SYSTEM 

KIDNEYS 

Decapsulation 1 

Nephrectomy 10 

Nephropexy 3 

Nephrolithotomy 7 

Nephrotomy 4 

Ureterectomy 2 

Ureterotomy 1 

BLADDER 

Cystectomy 1 

Cystorrhaphy 1 

Cystoscopy 11 

Cystostomy 1 

Cystotomy 4 

DEFORMITIES AND CONGENITAL MAL- 
FORMATIONS 

Division of double uterus 1 

Excision of scar 2 

Plastic repair on cleft palate 1 

Plastic repair on hare lip 3 

Plastic repair on nose 1 

Pozzi operation for infantile uterus. ... 6 

INJURIES 

Opening of sinus 2 

Removal of foreign body 6 

Suture of wound 6 

Wiring of jaw and teeth 1 

DISEASES DUE TO MICRO-ORGANISMS 

Incision of local infection 1 

NEOPLASMS 

Cauterization 6 

Excision 81 

Plastic on regions involved 16 

AMPUTATIONS 

Amputation through mid-forearm 1 

Amputation of finger 4 

Amputation at hip 1 

Amputation through metacarpals 1 

Amputation through upper thigh 1 

Amputation through lower thigh 3 

Amputation at knee 1 

Amputation through middle leg 1 

Amputation through metatarsus 1 

Amputation of toe 11 

Disarticulation at knee 1 

MISCELLANEOUS 

Radium treatment 18 



ESOPHAGEAL STRICTURES. 
Robert Abbe, M.D. 

It is but just to a novel surgical procedure, that after a sufficient 
number of years' trial the results should be checked up and a fair 
record of its established value should be made. 

By a fortunate observation, in 1892, in St. Luke's Hospital, while 
endeavoring to dilate a very tight resisting stricture of the lower 
esophagus, I found that a Billroth bougie (that is, a gum-elastic 
bougie, tipped with a metal conical point, in which a string was 
fastened for traction) was wedged so tightly that no reasonably safe 
pulling would bring it through the stricture. By accident of the 
moment, I happened to have another heavy braided silk thread along- 
side of it, passing from the open stomach wound to an opening in 
the upper esophagus, which I had made. 

When the stricture resistance absolutely prevented the bougie be- 
ing pulled through, a simultaneous pull on the parallel string moved 
the bougie unexpectedly forward. At once I saw that a back and 
forth, or sawing motion, of the independent string, wore away the 
resisting fibrous stricture while it was put on the stretch by the di- 
lating end of the bougie. Larger and larger bougies at once followed 
as the string completed the rasping or safe cutting of the stricture, 
and the esophagus was enlarged to its full caliber in a practically 
bloodless manner. 

An entirely new procedure was thus added to the armentarium 
of the surgeon in dealing with this hitherto inoperable disease of the 
esophagus. I say inoperable because, although numerous cutting in- 
struments had been devised to divide these tough strictures, they 
were uniformly condemned by surgical authorities as dangerous to 
use, because the thin-walled esophagus lies parallel to, and in contact 
with the aorta and vena cava. 

This happy experience, first published in the Medical Record, 
February 25, 1893, was accepted and adopted by surgeons generally, 
and has been incorporated in most surgical works as safe and efficient. 

39 



20 ST. LUKE'S HOSPITAL REPORTS 

"Without reviewing the large number of published and unpublished 
cases, I will speak only of my subsequent experience in our hospital. 

The good results are lasting if properly followed. 

The first case was of a young woman who had swallowed pure am- 
monia, with consequent inflamed esophagus and stricture. She was 
reduced to a desperate state when I did the above successful operation. 

During the subsequent year a full-sized bougie was passed to the 
stomach; at first, twice a week, then once a week, then monthly. 
During the years following, she passed it herself, several times yearly, 
until, after 10 years, she gave it up, as there was no tendency to 
recurrence. When I saw her, more than 15 years later, she was in 
perfect health, and I could detect no stricture even with a bougie 
a boule. That particular patient had a stricture of no great length, 
perhaps a half inch, though very tight, admitting merely a thread, 
following a whalebone filliform passed up from the opened stomach. 

Many cases which I have since operated on have uniformly shown 
long stretches of the esophagus (often one-third or one-half), showing 
tight, fibrous, solid remnants with the canal almost closed. 

Two of these are beautifully shown in the pictures, Figs 1 and 2. 

Another case, of which either of these pictures would be repre- 
sentative, was brought to me from Philadelphia, 6 or 7 years ago, 
and furnishes a fair illustration of what we may expect in the 
final outcome of such bad cases. The child was emaciated to a skeleton, 
and the best that could be offered to the parents by two of our most 
eminent surgeons, by other surgical methods, was, to create a gas- 
trostomy opening and thus feed the child for the rest of its life. 
I first created such an opening and fed the child until it was strong 
and hearty. Eight weeks later I did the string cutting esophagotomy. 

Dilatation was kept up for many weeks at first with anaesthesia 
for safety. Then, as the child bore it well, by easy passage of bougie. 

The family physician persisted, for 2 or 3 years, patiently and 
conscientiously, to pass the bougie, and the child ate everything, as 
other children. He writes me now that she has grown to be a fine, 
robust girl, and has a normal acting esophagus. 

It may be said of all these cases that they are caused by swal- 
lowing caustic or burning fluids. I have never seen or heard of 
a stricture following the long retention of foreign bodies in the 
esophagus, such as tooth-plates, toys, coins, etc., which necessarily 
make an ulcerated area after a few weeks. I judge nature is com- 
petent to dilate such narrowings by the ordinary bolus of food in 



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ESOPHAGEAL STRICTURES 21 

deglutition. It is the destructive type of inflammation similar to the 
urethral infective type, which destroys the epithelial lining and re- 
places the mucous and muscular coats by fibrous tissue, which we 
have to deal with. 

It may be asked — how can one expect ever to restore su .h a tube ? 
It is a fair question, and can only be answered by saying it is never 
restored to normal. That is, the muscular coat cannot be replaced. 

Nevertheless, a perfectly competent and practically useful tube 
is created by carving a channel through the fibrous mass — and keep- 
ing it open — until it has been lined by flat epithelium, through Na- 
ture's kindly and wonderful laws of repair, and until the contractile 
tendency of the formed tissue has ceased, as it does after months or 
years, according to the amount present. 

The same law of stenosis goes on precisely as in urethral strictures, 
unless dilatation is kept up at longer and longer intervals. The oc- 
casional passage of a bougie is a very small penalty to pay for a 
perfectly restored swallowing apparatus. 

Taken altogether, we can truly say that the annals of St. Luke's 
Hospital may be credited with the demonstration of a successful, safe 
and bloodless method of dealing with a bad surgical condition for 
which no other method is adapted. One may say that some strictures 
can be dilated, without cutting. That is true. And those should al- 
ways be dilated. But the majority are absolutely undilatable after 
they have become indurated by time, and to these, fortunately, this 
method offers complete cure. The surgeon, however, must be sure to 
follow up his patient if the result is to be permanent. That happy 
issue is now demonstrated by this report of 20 years' use. 



PAPILLOMA OF THE VOCAL CORDS. 

Robert Abbe, M.D. 

Warty vegetations on the vocal cords are the most obstinate of all 
surgical conditions in recurrence after removal — and most destructive 
to voice and breathing. It is said they sometimes change to cancer 
by irritation of the basal cells — but many do not. 

One of the most extraordinary illustrations of this persistence of 
type is shown in a woman of 60, who was first treated by intralaryn- 
geal excision by Dr. Elsberg, the pioneer laryngologist of America — 
who, more than 45 years ago, began to excise masses of these growths, 
and continued to do so 2 or 3 times yearly, during his life. He was 
succeeded by Dr. Lincoln, and later by Dr. Culbert, all experts, who, 
in order to give her breathing space, cleared away all visible growth 
every 6 months. Dr. Elsberg published her case (Trans. Am. Med. 
Assn., 1865) and Dr. Culbert reported upon it 40 years afterward 
(see ''The Laryngoscope," St. Louis, September, 1904), giving pic- 
tures of the original masses as illustrated by Elsberg. 

This case is one of four in which I have been called upon to use 
radium, and with the same effect, as shown by each case. 

Dr. Culbert held a device between the cords containing 20 mg. 
radium, for one-half hour. Three months later he reported almost 
all growth had gone from one side — quicker than by any removal 
with instruments which he had ever done. One year later he examined 
and reports it "to be the cleanest he had ever seen it. One-third of 
the inside of the larynx is entirely free from papilloma." One year 
later she was breathing even better, without further treatment, and 
growths were smaller. 

She then showed senile spinal paresis, and died. 

Two other cases, presenting great difficulties, but with fair demon- 
stration of the specific action in curing them that radium always 
shows in curing warts elsewhere, will be briefly mentioned before nar- 
rating the most brilliant result of a fourth case, herewith illustrated. 

The first is that of a woman, voiceless and with stridulous breath- 

22 





Fig. 1. 



Fig. 2. 





Fig. 3. 



Fie. 4. 





Fig. 5. 



Fig. G. 



PAPILLOMA OF THE VOCAL CORDS 23 

ing, from whom Dr. Josiah L. Barton had many times excised the 
papillomatous mass. To give her relief at first, I did a laryngotomy, 
and after excising the growths, applied monochloracetic acid to the 
base. Eecurrence took place. Radium was then intra-laryngeally 
applied. 

The result has been disappearance, and, later, small recurrence. 
The patient regained her voice well. The slight recurrence has given 
her no annoyance for a year past, and she has not come to the city, 
as she is entirely satisfied with her present condition — without fur- 
ther treatment. 

The second case is of a young child, whose recurrences filled the 
larynx, and the laryngologist had made a permanent tracheotomy not 
only with no relief, but an extension had followed downward in the 
trachea itself, so that a mass had grown on the posterior face of the 
trachea, opposite the opening. 

The child was so intolerant of laryngeal application of radium 
that I placed her in St. Luke's, and under ether, made a thorough 
use of strong radium, held in place one-half hour. The result was a 
diminution in the disease, but it required a second application, after 
6 months, to further control its growth. At the present time, there 
is still a visible mass, about one-third of the original, hidden below 
the vocal cords, and a very small remnant in the tracheal wound. 
There may be one additional treatment required to cure it, but it 
seems at present that the final cure by radium will be accomplished. 
An interval of many months is usually the best manner of admin- 
istration, inasmuch as the good effect always progresses that long be- 
fore one can judge whether a sufficient dosage has been given. 

The fourth case is a delightful demonstration of the cure of papil- 
loma laryngis by radium: 

A girl of 17 years had an unusually sweet singing voice, which she 
noticed became hoarse in July, 1910. She applied to Dr. Culbert in 
September following, who successfully removed a small tumor of the 
left vocal cord — which Dr. Ewing pronounced "fibroma" (Fig. 1). 
A rapid recurrence (Fig. 2), looking now like papilloma, was re- 
moved, but not examined. Again a rapid recurrence, looking now 
larger and more dusky, rather like a sarcoma than either papilloma 
or carcinoma. It occupied the central half of the cord, and overflowed 
into the ventricle. It was difficult to control the anaesthesia of this 
patient's larynx so as to make an adequate radium application, though 
it was carefully tried. The growth progressed and now seemed typi- 



24 ST. LUKE'S HOSPITAL REPORTS 

cally papillomatous — obstructing respiration (the voice was gone en- 
tirely) (Fig. 3). By the following June it occupied most of the left 
and much of the right vocal cord. The pictures accompanying show 
its varied stages, the condition immediately before operation being 
shown in Fig. 4. 

On June 14th, I decided to make a thorough radium application 
under anaesthesia. Through a tracheotomy wound, I passed a wire up 
to the mouth and drew into the trachea a tube containing 100 milli- 
grammes of pure radium, which I was able to suspend with accuracy 
between the vocal cords. 

This I kept in situ half an hour, while ether was given through 
the tracheal tube. Nothing else was done except to allow the tube 
to remain a few days in the trachea, for safety. The wound healed 
at once on its removal. 

Three months afterward (Fig. 5) the patient talked and sang 
perfectly. 

Examination of the larynx showed and continues to show an appar- 
ently normal condition (Fig. 6), with clean, white vocal cord. The 
singing voice is restored completely, and is as sweet as ever. 

This perfect condition remains after one year. 



RUPTURE OF THE KIDNEY IN CHILDREN * 

Charles L. Gibson, M.D. 

Ruptures or other subcutaneous injuries are very uncommon in 
children, only 22 cases being reported in Watson's 1 tables. My ex- 
perience comprises 4 cases of complete rupture in children from 8 to 
12 years old, and a consideration of the conditions found furnishes 
some interesting features. 

Case 1.— Barbara S., age 10. Admitted to St. Luke's Hospital Aug. 25, 1902. 
Two weeks ago was kicked by a horse on the right side of the body ; unconscious 
for a while. Next morning urine contained some blood ; none seen since. Some 
swelling of the right side developed, with a considerable amount of pain. 
Has had no chills, but there have been fever and sweating. 

Physical examination showed a bright, healthy child, with a visible swell- 
ing of the right lumbar region. No superficial discoloration. The swelling 
was elastic, insensitive to pressure, flat on percussion. 

Urine. — Acid 1018, no albumen. 

Operation. — Right lumbar incision showed the swelling to be a large 
retroperitoneal accumulation of normal appearing urine. The kidney was 
ruptured in two, the lower pole entirely separated from the upper three- 
fourths of the viscus. Nephrectomy ; good recovery. Discharged Oct. 3. 

Case 2. — These details are as exact as I can furnish them from memory, 
the record being lost. 

Boy, about 10, admitted to the Hudson Street Hospital, probably in the 
summer of 1907 ; run-over injury ; abdominal symptoms ; median laparotomy 
by a colleague; negative findings. Seen by me several days later; diagnosis 
of rupture of left kidney. Lumbar incision revealed complete tear of left 
kidney. Nephrectomy ; good recovery. 

Case 3.— James L., 12. Admitted November, 1909, to the Hudson Street 
Hospital. While running across the street, an automobile struck him in the 
left side, knocking him d6wn. Scalp wound, requiring two stitches. Brought 
to the hospital by the guilty automobile. Soon began to complain of great 
pain and tenderness over the left kidney region. 

Physical Examination: Tenderness and rigidity in left hypochondrium, 



*Read before the Section of Surgery of the New York State Medical 
Society, April 17, 1912. 

'Watson and Cunningham, Genito Urinary Diseases, vol. ii. 

25 



26 ST. LUKE'S HOSPITAL REPORTS 

also some slight discoloration. Skin and mucous membranes of good color. 
Shortly after admission passed blood-tinged urine. Hemoglobin color index 
70 per cent. 

Operation : About eight hours after injury ; left lumbar incision. Com- 
plete rupture of kidney in two pieces. Nephrectomy ; drain ; good recovery. 
Highest temperature, 100%° F. Discharged in three weeks. 

Case 4.— M. S., girl, aged 8, admitted to St. Luke's Hospital July 26, 1910, 
complaining of pain in the "stomach." Two days before she had fallen a 
distance of four and a half feet, landing on the ground on the right side. 
Went home ; complained of pain in her stomach, which has continued ever 
since. Bowels regular. No trouble with urination ; no blood in the urine ; 
has vomited twice. 

Physical Examination : Negative, except for the abdomen, which shows 
general rigidity, with tenderness on the lower right side. Temperature, 102° F. 
Blood count : Leucocytoses, 2,500 ; polynuclears, 88 per cent. No urine record. 
Probable diagnosis, appendicitis. Immediate operation. Intermuscular in- 
cision. On separating the muscles a considerable amount of fluid blood evacu- 
ated. On opening the peritoneum a similar fluid escaped from the pelvis; 
the ccecal wall was the site of a considerable ecchymosis. Appendix normal 
(removed). The wound was dilated retroperitoneally to aliow of a sponge 
being pushed up into the lumbar region ; it returned bloody,- but without evacu- 
ating any fluid. Injury to the kidney seemed probable; it could be palpated 
quite readily, but no obvious abnormality being detected (intra-capsular 
rupture), it was decided to await further developments. 

The child recovered well, and seemed relieved. The urine the next day 
(17th) was: Neutral 1,034, very faint trace albumen, a few hyaline casts; 
July 20, acid 1,014, very faint trace albumen, a few leucocytes ; July 21, acid 
1,020, albumen 10 per cent, many red blood cells. In view of this last urine 
report, exploration was undertaken. Right lumbar incision. The true capsule 
was found intact, but distended with blood, and raised from the kidney. 
On opening it, the kidney was found broken completely in two, the lower 
smaller fragment showing beginning necrosis. Nephrectomy ; drain. Perfect 
recovery. Discharged Aug. 9. 

The case is interesting, showing a complete rupture resulting from 
a relatively slight trauma, leaving no mark on the body and producing 
absolutely no shock, the masking of kidney symptoms by the bruising 
of the lower abdominal muscles and the colon, the absence of any 
urinary symptoms till five days after injury, and also that the 
kidney may be divided completely in two without appreciable solution 
of continuity of its capsule. Four complete ruptures of the kidney 
in children under 12, occurring in the practice of one surgeon, seems 
unusual, in view of the small number of such cases on record. It is 
possible that these cases are really not so rare and may be overlooked, 
with disastrous results, by those who hesitate to interfere in dubious 
cases. The similarity of the lesions is interesting, being exactly alike 




-.1} 



RUPTURE OF THE KIDNEY IN CHILDREN 27 

in all 4 cases — complete division of the viscus in 2 parts, the lower 
one being the lesser. In one instance the capsule remained untorn. 

The fact that the kidney lesions were the same with the different 
kinds of violence seems to confirm the theory of "bursting" by hy- 
draulic pressure. Also the line of rupture — vertical to the long axis 
at about the junction of the two lower thirds would seem to indicate 
that we had here an instance of a definite line of least resistance 
such as I have not seen indicated in any of the treatises on the sub- 
ject. 

Although the lesion in all these cases was severe, the symptoms, on 
the whole, were mild, and in several ways deficient. Nephrectomy 
was necessary in every instance, and successful; no other operation 
would have been permissible. Three of the children have been under 
observation and remained well. 

As regards the etiology of such severe injuries, it is obvious that 
children are relatively little exposed to the various forms of trauma 
commonly encountered by active men (96 per cent of all cases). Most 
modern observations seem to corroborate Kuttner's view, that the 
kidney being a semi-fluid body, bursts along the line of least resistance 
according to the law of hydraulics. Direct pressure from the lower 
ribs can also explain it. It is less easy, however, to understand the 
effects of indirect violence as from a fall on the feet. A point, how- 
ever, to be borne in mind, illustrated in two of my cases, is that the 
severest form of damage may result from an injury unaccompanied 
by marks of external violence on the surface of the body in the kidney 
region or anywhere else. Possibly in some children a persistence of 
the infantile ptosis 2 may persist, leaving more of the surface unpro- 
tected by the thoracic bulwark. The particular vulnerability in child- 
hood has also been ascribed to the minimum deposit of perinephric 
fat and the greater tension of the overlying peritoneum. 

The extent of the lesion naturally runs the gamut from the mildest 
of superficial bruises to the complete rupture observed in my 4 cases — 
to the tearing away of the kidney from its vascular pedicle or the 
ureter or complete pulpifying from extraordinary crushes. In the 
less extensive injuries it is of practical importance whether the tear 
involves or extends into the pelvis — whether larger vascular trunks 
are destroyed, with resulting dangerous hemorrhage or jeopardizing 
the future vitality of portions of the organ — whether the injury is 

s Aglave, Bulletin de la Soc. d'Anatomie de Paris, 1910, p. 595. 



28 ST. LUKE'S HOSPITAL REPORTS 

subcapsular, and finally, whether there is a coexistent tear of the 
peritoneum or injury of the contiguous viscera. Unfortunately, few 
if any of these lesions can be diagnosticated with certainty as regards 
their extent, particularly at a period when early interference may be 
all-important. A consideration of the nature of the violence is help- 
ful. Injuries resulting from direct violence will probably produce a 
rupture of the kidney alone by "bursting" violence. Gross, direct 
violence, such as "run over" accidents, are more likely to result in 
complex lesions. The intensity of the violence is, however, not a 
trustworthy guide, as shown by Case I, where a complete rupture re- 
sulted from the kick of a horse that left no mark on the skin. It 
must also be borne in mind that a pathological kidney may rupture 
from the most trivial accident (Watson's case of the woman whose 
hydronephrotic kidney ruptured from muscular action — washing 
windows). 

The loss of blood resulting from any of these injuries naturally 
varies. Generally speaking, it is rarely sufficient to endanger life 
quickly; it is, rather, the constant and recurring hemorrhage that is 
most to be dreaded. Even with extensive rents of the kidney, the 
integrity of the capsule tends, by tension, to check extraordinary 
bleeding. 

As regards diagnosis, it may be stated broadly that a diagnosis 
of some degree of injury to the kidney presents little difficulty. Sta- 
tistics give a history of hematuria in 80 per cent of the cases, and 
certainly, with painstaking microscopic urinary examinations, this 
figure would be increased. It will not ordinarily be difficult to ex- 
clude lesions of other portions of the urinary tract, e.g., of the blad- 
der, practically always complicated by a fracture of the pelvis. The 
history or evidence of an injury which may implicate the kidney will 
generally be elicited, pain, tenderness and eventually more or less 
pronounced signs of the extravasation of blood or urine, or both, in the 
marked cases, will accentuate the diagnosis and also indicate the side 
involved. For unusual cases and conditions, the cystoscope or ureter 
catheter may be used; but as a routine, these are uncalled for, as 
well as unwise, and in children can scarcely ever be used, and if re- 
quiring anesthesia, had better be replaced by a harmless and more 
satisfying exploratory and therapeutic lumbar incision. 

What is most difficult is to determine the extent of the lesion, and 
particularly as regards the conditions which most urgently call for 
interference. The initial symptoms, with the exception of the degree 



RUPTURE OF THE KIDNEY IN CHILDREN 29 

of shock and hemorrhage, do not present any features which sharply 
indicate the severity of the damage — it is rather on the development 
and sequence of secondary manifestation that we have to rely, or, 
perhaps, waste valuable time. 

Very severe injuries or very mild ones may be usually diagnosed 
with readiness, especially with a definite knowledge and appreciation 
of the nature of the causative violence. For instance, a child is run 
over by a heavy wagon, as reported by a competent witness — there 
are extensive marks on the body, there is abundant and early, perhaps 
immediate, hematuria, there is marked shock. Given these conditions, 
there should be a severe laceration of the kidney and perhaps of other 
contiguous organs, possibly entailing a laceration of the peritoneum 
overlying the kidney. These complicating conditions may not always 
be obvious at the outset, although these marked and dangerous symp- 
toms will manifest themselves later — too late, probably, to remedy 
them. 

On the other hand, a lad may be hit a severe blow in boxing — the 
so-called "kidney blow" — feels a good deal of pain, may be tem- 
porarily dizzy or sick at his stomach, sooner or later the urine is 
tinged with blood. Such a history and such findings indicate a tri- 
fling condition requiring no active treatment. 

It is, however, the cases of moderate severity or of incomplete 
symptoms that are the most difficult to judge. The degree of initial 
shock is alone no criterion; it may be intense, certainly, for a short 
time, with only a trifling injury ; it may be insignificant or wanting, 
with the severest damage. The degree of hemorrhage is also mis- 
leading; a small vessel may bleed savagely for a while, and if the 
bulk of the hemorrhage finds a ready escape down the ureter we shall 
have an alarming picture for a perhaps trifling condition. On the 
other hand, mechanical obstacles — rupture of the pelvis or ureter (or 
blocking), clotting or absence of considerable hemorrhage from the 
kidney, may result in little hematuria even in the presence of the 
severest damage. 

Absence of visible marks of external violence is no criterion, for 
complete rupture may occur despite this negative evidence (Cases I 
and IV). 

The significance of a swelling in the flank varies a good deal. If 
considerable and early, it usually means extensive damage. Some 
of it may be due to the trauma to the abdominal wall, some to the bulk 
of the extravasated blood, some to the reaction of irritated intestines 



30 ST. LUKE'S HOSPITAL REPORTS 

inhibiting peristalsis, or to an actual lesion of the gut, or later, to a 
peritonitis due to extravasation of urine, or an infection of the 
retroperitoneal tissues or from associated injuries. 

The amount of urine collecting in the tissues will depend on 
whether the injury involves a rupture of (a) the capsule, (b) pelvis, 
(c) ureter, and whether the urine can accumulate in a well-defined 
space, or whether opportunity is offered for extravasation into the 
tissues or the peritoneum. Tuffier has shown from animal experi- 
ments, and clinical observations have corroborated that the lacerated 
renal surface per se allows little or no urine to escape. 

Later swellings may be due to secondary infections. A consider- 
able and increasing, well-defined (colon pushed forward) swelling 
with remission of acute symptoms and absence of inflammatory signs 
would indicate the retroperitoneal accumulation of a well walled-off 
collection of urine whose escape down the ureter is shut off — explora- 
tory puncture (if deemed wise) will prove the condition. 

It is obvious that we are not able to diagnosticate accurately the 
extent of many of these lesions. We know also that many such in- 
juries, while not rapidly producing death, may do so eventually on 
account of the many complications that may arise. My feeling is that 
we should not hesitate in dubious cases to complete our diagnosis by 
an early exploratory lumbar incision, which will also fill a useful and 
probably necessary therapeutic role. Not many years ago we thought 
ourselves competent to differentiate the several forms of appendicitis 
— few surgeons to-day care to take such a risk, and prefer to replace 
doubt with certainty, and I believe that the varying possibilities for 
harm of a kidney lesion furnish a reasonable analogy. 

As regards prognosis, statistical data of large series of cases have 
been collected to show results both of the condition and the value of 
the various forms of treatment, but it is doubtful if the older figures 
have much value to-day. 

Suter, 3 in 1905, found in a study of 701 subcutaneous injuries of 

the kidney : 

Per cent 

Total mortality 18.6 

of 131 treated by nephrectomy 16.7 

" " " 143 conservative operations 14.6 

" 427 treated expectantly 20.6 

If these figures are of any value at all, certainly an expectant 

'Suter, Beit, zur klin. Chirurgie, Band 47. 



RUPTURE OF THE KIDNEY IN CHILDREN 31 

treatment which has a mortality of over 20 per cent does not make 
a very impressive showing. With modern technique, generalization 
of skilled operators, efficient means of combating shock, etc., to refrain 
from operation satisfied with a mortality of 20 per cent, cannot be 
accepted as progress. Watson showed, in a series of 99 cases of oper- 
ation in which the condition of the kidney called only for minor pro- 
cedure, there were only 7 deaths, the cause of death being found, 
generally, to conditions independent of the operation proper (injury 
of the other kidney, peritonitis). Watson has formulated the indica- 
tion for treatment as follows: 

Cases suitable for expectant treatment : 

1. The milder forms of the injury. 

2. The cases in which there is reason to believe that both kidneys have 

been injured, the signs being external evidence of injury on both 
sides, tumor in both loins, and anuria. 

3. Cases in which there are injuries of other parts of the body of such 

grave character as to make futile any operative treatment of the 
renal lesion. 
Cases demanding operative treatment : 

1. All in which there is evidence of progressive hemorrhage, e.g., increas- 

ing pallor, pulse of declining strength and increasing rapidity, sigh- 
ing respiration, and, locally, a tumor in the loin which is increasing 
in size ; or an increasing amount of free fluid in the peritoneal 
cavity in the cases complicated by intra-abdominal injuries. 

2. Hematuria which persists for a long time, even though the quantity 

of blood is at no one time large ; hematuria in which there is a large 
amount of blood, even though it has not lasted long; hematuria 
which recurs after having ceased ; sudden cessation of a previously 
profuse hematuria, and, if there is no reason to believe that both 
kidneys are injured. 

4. Cases in which there is evidence of intra- or perirenal suppuration, 

or of peritoneal infection. 

My own feeling would be that we should refrain from immediate 
operation in (a) all milder cases, presenting no one symptom of any 
severity, and giving a history of injury w T hich is presumably of no 
great violence ; (b) cases of generalized injury with a very bad general 
condition, and absence of urgent kidney symptoms. 

For the latter class I would urge an exploratory operation with 
an appreciable increase of any or all symptoms at an early date. 
Operation in some form, then, is indicated for all milder cases that 
show a tendency to increase their symptoms and for all other cases, 
barring those falling in class B. My attitude in the border-line cases 
would be, when in doubt operate, believing that by such a routine 



32 ST. LUKE'S HOSPITAL REPORTS 

measure we will not let some seemingly mild case slip through our 
fingers. As regards the time of operation, in general, one should 
operate as early as possible, but if the main symptom is not that of 
an increasing anemia (repeated examinations of the hemoglobin), 
one might well occasionally give the patient a few hours to pull him- 
self together, though such a delay should not be entertained if we 
have associated intraperitoneal injuries calling for prompt relief. 

As a rule, the incision should give an extra-peritoneal approach by 
the lumbar route — it is the most direct, avoids infecting the perito- 
neum, and does not require handling and blocking off of protruding 
intestines. Moreover, it will provide the safe and efficient drainage 
demanded in most of these conditions. An anterior incision should be 
reserved for injuries which presumably involve the intraperitoneal 
organs — even in these cases a supplementary lumbar incision for 
drainage may be indicated, particularly if a nephrectomy is not per- 
formed. 

Nephrectomy should be reserved for the cases in which the integ- 
rity of the kidney cannot be preserved, and it is obvious that hemor- 
rhage cannot be effectually stopped or prevented otherwise, or the 
outflow of the urine into the ureter cannot be efficiently restored. In 
the event of doubt arising, regarding the integrity of the other kid- 
ney, nephrectomy may be deferred until sufficient information is ob- 
tained. Meanwhile, the injured kidney should be attended to, per- 
itoneum if torn, sutured or packed, laceration sewn if advisable, the 
pelvis drained and the whole or part of the wound packed and drained 
efficiently. Where nephrectomy is not required suture or packing 
with drainage will suffice. How much more efficient suture rather 
than packing a lacerated area will prove, is to me an open question. 
I think not much time should be lost in performing it and it should 
perhaps be reserved for cases in which packing may less efficiently 
check bleeding. The main indication is to provide free drainage, 
which will minimize the disastrous secondary effects of injury and 
extravasation. 

This paper is written to call attention to the fact that rupture of 
the kidney in children is probably commoner than generally esti- 
mated. That the lesion is frequently severe, consisting of a complete 
division of the kidney into unequal halves. That shock and other 
symptoms may be slight and out of proportion to the gravity of the 
lesion. That operative interference should be more freely employed 
and gives good results. 



THE SURGICAL TREATMENT OF COLITIS.* 

Charles L. Gibson, M.D. 

My interest in the surgical treatment of colitis dates back to 1900, 
when I devised a line of treatment intended to replace the only means 
recognized then as efficient, namely, artificial anus. This method of 
mine is the one most generally used to-day ; but its origin and useful- 
ness has been considerably obscured by the introduction of a modifica- 
tion in the technique of my original operation by Weir, substituting 
for my valvular caecostomy appendicostomy. I hope to be pardoned if 
I make this paper the subject of a review of the development of the 
more modern treatment. 

As regards the value of the artificial anus, I had been very skeptical, 
in the brief years it flourished, whether the cure was not worse than 
the disease. Moreover, the evidence advanced of its curative value 
was oftentimes unconvincing, and it was natural that the relief ob- 
tained should only be partial unless a complete artificial anus was 
made, absolutely eliminating the fecal current from reacting the colon. 
If a complete artificial anus were made, its eventual repair required 
a severe operation with a high mortality. 

I set out deliberately to devise a form of operative treatment that 
should be the antithesis of the artificial anus, allowing of no escape 
of fecal contents. 

I felt that if the principles of ordinary surgical drainage and clean- 
liness could be applied to the large intestine, we would have gained 
considerably in facilitating the healing of the ulcerated surfaces. That 
result I thought could be brought about by devising a means of fre- 
quently flushing the large intestine, greatly diluting its irritating 
contents and removing them from prolonged contact with the ulcer- 
ations. So if we could give the patient an opening in the bowel for 
access to its contents and yet prevent their egress, the problem would 
be solved. 

The Kader form of gastrostomy had then come to be considerably 

♦Read before the International Surgical Association at Brussels, September, 

1911. 

33 



34 ST. LUKE'S HOSPITAL REPORTS 

employed, and all I had to do was to use the same technique in the 
caecum which I did. At the outset I believed that by making a suitable 
incision (intermuscular) we should have a small and easily controlled 
wound, confinement to bed for its healing 10 days or less, the patient 
could then receive ambulant treatment or administer it himself by 
introducing the tube several times a day and flushing out the bowel 
with various appropriate solutions. During the intervals neither tube 
nor dressing need be worn, and the closure of the wound would be 
automatic as the discontinuance of the passage of the tube for a few 
days would allow of the valve action to become permanent. 

All these theoretical requirements were found in general to be 
feasible in practice ; but owing to the introduction of appendicostomy 
two years later, the origin of the method was lost sight of. I was a 
long time in getting an opportunity to perform this operation myself ; 
but two of my kind friends, to whom I described this procedure, were 
good enough to make a trial of it at my suggestion. 

Dr. P. R. Bolton performed it in 1900, reporting the case in the 
Medical Record for March 16, 1901, and in November, 1901, Dr. F. H. 
Markoe also performed it at my suggestion. My first case was per- 
formed later in 1901. The method was described in a paper 1 read by 
me March 5, 1902, in Boston, but publication was delayed till Sep- 
tember. 

Dr. Weir, in April, 1902, did my operation at my suggestion. The 
same day he had a second ease, and having had some difficulty with 
my technique (tube was pulled out after being put in place), decided 
to use the lumen of the appendix as the channel. He lost no time in 
getting into print, so that, when my article appeared, appendicostomy 
had already been claimed as the proper treatment for colitis, and is 
generally so used. I think, whatever its merits from the technical 
standpoint, that the modern treatment owes its origin distinctly to me. 
That is, if I had not shown Dr. Weir how to do a valvular colostomy, 
he never would have thought of treating colitis except by the forma- 
tion of an artificial anus. 

I cheerfully recognize the merits of appendicostomy. It is a little 
simpler for a person without much surgical skill to perform, and there- 
fore safer. The appendix may, however, not be of a suitable size or 
position (retrocecal) to lend itself properly to the procedure, and the 

'The Creation of an Artificial Valvular Fistula for the Treatment of Chronic 
Colitis (Boston Medical and Surgical Journal, Sept. 25, 1902). 



THE SURGICAL TREATMENT OF COLITIS 35 

patient has to wear constantly a dressing, which is not the case with 
my technique. 

So there still remains some sphere of usefulness to the original 
operation, and I repeat its original description, as given in the Boston 
Medical and Surgical Journal, September 25, 1902. 

The technique is as follows: A small incision — preferably the 
McBurney intermuscular — is made over the caput coli. If desirable, 
the anaesthetic can be discontinued as soon as the peritoneum is 
opened. Nitrous oxide gas anaesthesia might be used. With an in- 
telligent and self-controlled patient local anaesthesia might suffice. 
Should there be any difficulty in bringing the colon to the surface, I 
see no positive disadvantage in utilizing the lower ileum. Two Lem- 
bert sutures, half an inch apart, are inserted, and the caecum opened 
between them. A soft catheter, about 30° F., is introduced so that 
it projects well into the bowel, and the original sutures tightly tied. 
The wall of the gut is further infolded around the tube in two super- 
imposed layers. The ends of the superficial layer are used to suture 
and hold the caecum to the musculo-aponeurotic structures. The tube 
may also be secured in place by passing a finer catgut stitch through 
its wall. The abdominal wound is closed at the angles, or packed. It 
will be safer not to begin irrigation before 3 or 4 days. The tube 
may be withdrawn in a week or 10 days, being introduced only when 
necessary for the irrigation, and withdrawn so soon as it has served 
its purpose. If our ideal has been attained, there will be no leakage, 
even when the colon is visibly distended. Treatment should be per- 
sisted in till a cure is obtained. Closure of the fistula occurs spon- 
taneously with the discontinuance of the daily passage of the catheter. 

It seems to me unwise, if not impossible, to attempt at present to 
formulate any indications for the employment of this measure. From 
what has been related, it is fair to say that certain forms of colitis can 
be cured by it. It may be objected that such cases and the ones here 
described are of the milder variety that would yield to the orthodox 
treatment. Personally, it seems that the results have been more di- 
rect, progressive and prompt than are attained by the non-operative 
measures. 

On the other hand, I do not cherish any illusions regarding certain 
forms of ulceration, such as the tubercular, that may be properly con- 
sidered as incurable, especially when accompanied with similar or 
more extensive changes in the small intestine. Actual experience 
only can determine whether by frequent cleansing of these ulcerating 



36 ST. LUKE'S HOSPITAL REPORTS 

surfaces and by neutralization of the products of decomposition we 
can somewhat ameliorate the symptoms, and if to an extent that war- 
rants actual interference. 

With regard to the therapeutic agents that may prove of value 
when so locally applied, I can only indicate those ordinarily employed. 
For the present I shall rely principally on the mechanical cleansing by 
flushing the bowel with an appropriate bland solution, such as the 
normal saline. It may either be used as a continued irrigation, escap- 
ing through the rectal tube, or the colon may be filled to moderate 
distention, say 3 quarts, and subsequently evacuated. The frequency 
should be established by the tolerance of the bowel and the urgency 
of the symptoms. At the beginning, if well borne, I should prefer to 
repeat the irrigation at regular intervals of 8 or 12 hours, possibly 
oftener. Agents destined to exert a direct influence on the ulcerating 
surfaces will naturally act better after the preliminary cleansing. 
They should be introduced separately from the saline, or after it has 
been evacuated. The bowel should be flushed with plain water prior 
to the use of substances such as AgN0 3 , which combine with the 
saline. 

The required therapeutic agents will also vary somewhat with the 
nature of the colitis. Gradually increasing strengths of quinin and 
methylene-blue have been recommended for the amoebic form. Nitrate 
of silver in strengths increased from 1-20,000 will, I think, prove the 
best single remedial and stimulating agent. The whole gamut of the 
milder non-poisonous antiseptics, especially of the naphthol group, 
may be tried, as well as the ordinary astringents. Small doses of iodo- 
form in emulsion might be tentatively tried in the tubercular form. 
Glutol, a non-irritating derivative of formalin, which acts so admir- 
ably in ordinary suppurations, might also be employed. The patient 
should be on an appropriate, chiefly proteid, diet. 

My own experience is very small, but gratifying. Six cases. One 
tubercular case (unsuitable) was not improved. Four cases were 
cured. In one subsequently operated upon by another surgeon for 
another condition, marked healing of many of the ulcerated areas 
was found. One patient almost moribund was operated upon with 
local anaesthesia very satisfactorily and was completely restored to 
health. 

None of these cases was of the amoebic variety, which I believe is 
hard to cure by this or any other means, and are liable to undergo 
relapse sometimes after long intervals of freedom from symptoms. 






:f. 



FECAL CONCRETION IN THE FALLOPIAN TUBE. 
Walton Martin, M.D. 

On March 8, 1911, a Swedish girl, 20 years old, unmarried, was 
admitted to the hospital. She had been ill for 2 weeks. During that 
time she had had severe sharp pain in the lower right quadrant of the 
abdomen. The pain had not been constant, but had occurred at in- 
tervals. She had felt ill, and had had fever. There had been no 
disturbance with bowel or bladder. 

On examination, there was well marked rigidity on both sides of 
the lower abdomen, but it was more marked on the right side. The 
patient looked ill. The temperature was 101°, the pulse 142. 

The diagnosis of appendicitis was made, and operation was done 
as soon as the patient could be prepared. On opening the peritoneum, 
there was a gush of foul-smelling pus. The appendix had partly 
sloughed away and only the proximal end could be found. This was 
removed and a drainage tube introduced. 

The patient made a slow but satisfactory recovery and left the hos- 
pital 5 weeks later, with a normal temperature. There was still, 
however, a discharging sinus at the site of the incision. The dis- 
charge was purulent and foul-smelling, but not fecal. A probe could 
readily be passed for several inches along a fistulous tract. 

The patient returned to her work, but reported at the hospital 
from time to time, and on August 7, 1911, 4 months after her first 
operation, she was again admitted, as she still had the discharging 
abdominal sinus. This sinus seemed to have changed little since she 
had left the hospital. From time to time it had discharged small 
amounts of very foul pus, and she had had, at times, considerable 
pain in her side. It was evidently not a fecal fistula, and the per- 
sistence of the sinus was supposed to be due to the failure to remove 
the distal portion of the appendix. It was supposed that the presence 
of this distal portion was causing the trouble. An operation was 
advised. 

On August 8, 1911, an incision, circumscribing the old scar, was 

37 



38 ST. LUKE'S HOSPITAL REPORTS 

made, and the fistulous tract carefully dissected out. The tract led 
downward and inward between loops of intestine, until it reached 
a dark purple, tubular mass about the size of the index finger; from 
the end of this structure pus was exuding through a pin-point open- 
ing. Followed mesially this structure became narrower and finally 
joined the uterus. It was obviously the uterine tube. It was re- 
moved, and the abdominal wall closed. The wound healed satisfac- 
torily, and the patient left the hospital at the end of 3 weeks. 

The specimen removed was tubular and 8 cm. long. It measured 
0.5 cm. at the uterine end, and 2 cm. at the distal end. On cutting it 
open, a fecal concretion, about 1 cm. in length, was seen in the lumen of 
the thickened distal portion. It was identical in appearance with a 
fecal concretion such as is usually seen in the appendix. There was 
pus in this portion of the tube ; it had a foul, fecal odor. The fimbriae 
at the outer end of the tube were turned in, so that the end of the 
tube looked club-shaped, as in the ordinary pyosalpinx. Microscopic 
examination snowed the walls of the Fallopian tube thickened and 
infiltrated with round cells. 

The concretion had evidently been freed during the attack of ap- 
pendicitis by the sloughing away of the appendix, and had been taken 
up by the Fallopian tube, where it had found lodgment for 4 months. 
The irritation of the concretion in the tube caused the constant escape 
of pus through the end of the tube into the abdominal sinus. 

I have been unable to find the record of a similar case. 



EXTENSIVE EPITHELIOMA OF THE CHEEK WITH SEC- 
ONDARY INVOLVEMENT OF THE GENIAL GLANDS. 

H. H. M. Lyle, M.D. 

Although the genial or facial glands were not mentioned by the 
majority of the older writers (Richet, Bouchard, Sappey, etc.), Mas- 
cagni described them in 1787, distinguishing the supra-maxillary and 
buccinator groups. Boyer, Jacob and Cruveilhier also mention them. 
In 1887, Poncet called attention to the clinical significance of these 
glands; his work was further extended by his pupils, Vigier (1892), 
Albertin (1895). This clinical work stimulated an interest in the 
subject and brought out researches by Princetau (1899), Cappette- 
Laplene (1899), Buchbinder (1899), Kiittner, Trendel, Thevenot 
(1900). 

The glands are found in 65 per cent of the cases. According to 
Cuneo and Poirer, they can be divided into three sets. An inferior or 
supra-maxillary group, situated on the external surface of the inferior 
maxilla, close to the facial vessels. The middle or buccinator group 
(Molar of Testut and Jacob) are situated on the external surface of 
the buccinator, in front of the anterior border of the masseter; they 
are in close relation to Stenson's duct. The superior or molar group 
when present, are found along the ascending branches of the facial, 
one in the supra-orbital region, a second in naso-genial fold, and a 
third on the malar bone. 

Trendel has collected 25 cases of secondary cancerous involvement 
of these glands; cases are also reported by V. Bruns, Kiittner and 
others. 

In the light of these facts the following case occurring on the ser- 
vice of Dr. Gibson, is of interest : 

The patient, a man, 52 years old, was admitted to St. Luke's Hospital 
September, 1910. He had a tumor of the left cheek, of 11 weeks' duration. 
Ten days previously his physician had incised the tumor, but no pus was 
found. 

On examination, there was a large, indurated swelling occupying the left 

39 



40 



ST. LUKE'S HOSPITAL REPORTS 



cheek and involving the angle of the mouth. In the center of the mass 
there was a discharging sinus. The buccal surface showed a cauliflower- 
like growth, which was not attached to the jaw. The sub-maxillary lym- 
phatics were enlarged and hard. A section of the growth removed for ex- 
amination showed it to be a squamous-celled carcinoma. 

Operation.— A wide excision of the growth, including the angle of the 
mouth, was made, and the defect closed by a modification of the Dowd 
operation, plus a flap taken from the neck. Primary union resulted. Ten 
days previously a block dissection of the neck and sub-maxillary and sub- 
mental regions had been done. 




Fig. 1. — A, original growth. B, recurrence in Buccinator group of genial 
glands. C, recurrence in the inferior group. The dotted outline indicates the 
amount of skin removed. 

Four months later, when the patient returned for observation, an 
examination showed that the mucoperiosteum of the jaw had been in- 
volved, and there were two distinct hard nodules on the cheek, one 
just below the center of the malar bone; the second an inch lower 
down and posterior to the angle of the mouth. There was no cervical 
involvement. 

At a second operation, virtually the whole cheek below the malar 
bone was removed, along with the fascia and fat covering the masseter. 
In this fascia, the buccinator and supra-maxillary groups of the genial 




Fit:. 2. — The result, after the removal of a large 
portion of left cheek, the angle and floor of the 
mouth, and half the body of the lower jaw. 



EPITHELIOMA OF THE CHEEK 



41 



glands were found to be involved. The left half of the body of the 
jaw, with the involved mucous membrane of the floor of the mouth, 
was removed. Cutaneous flaps were obtained from the neck and the 
right side of the chin. Considerable difficulty was experienced, ow- 
ing to the cicatricial tissue left from the previous operation. The 
buccal lining of these flaps was obtained by splitting the mucous 
membrane of the tongue and turning it upward, after the method 
suggested by Sonnenburg. 





Fig. 3. — Sagittal section through the mouth, after removal of a large por- 
tion of the cheek and half the lower jaw, showing the method of closing the 
defect by flap from the tongue. 



Three months later a secondary plastic operation was performed 
to widen the cavity of the mouth. 

The points of interest in the case are: (1) the involvement of 
the genial glands, failure to recognize and remove these at the time 
of the primary operation having been one of the causes of the recur- 
rence; (2) the use of a flap of mucous membrane from the tongue 
to line the cheek. 



THE BOTTLE OPERATION FOR HYDROCELE OF THE 
TUNICA VAGINALIS— TEN CASES— THREE FAILURES. 

H. H. M. Lyle, M.D. 

In order to get the true value of any surgical procedure it is 
necessary to report the failures as well as the successes. In Keen's 
Surgery, volume IV, page 607, in describing the "Bottle Operation," 
Bevan quotes E. Wyllys Andrews as follows: "I recommend it with- 
out reserve and do not hesitate to urge that it supersede the older 
operations. ' ' 

The following is a brief account of our experience with the "Bottle 
Operation." In a series of 10 cases we have had 3 failures. The 
first of these failures could not be justly charged to the operation. 
The patient had a chronic cardiac condition, which might have been 
a factor in the passive congestion of the reversed sac. In the second 
case, the surgical indications for this operation were apparently per- 
fect. The failure was a complete surprise, and led us to think that it 
was due to some error in technic. As the patient refused further 
operative treatment, the cause of the increased size of the sac and 
testicle remained problematic. In the third case, with the previous 
failures freshly in mind, the operation was carefully and deliberately 
carried out. The hydrocele tumor disappeared, but its place was 
gradually taken by a tumor composed of thickened sac and testis, 
This secondary condition was little or no better than the primary. 
Two months later the reversed sac was excised by Dr. Douglas. The 
sac wall, which measured one-half inch thick, was composed of ede- 
matous connective tissue. 

The patient was shown before the New York Surgical Society, 
November 8, 1911. The discussion of the case brought out the fact 
that this operation had failed in the hands of other surgeons. Dr. 
A. V. Moschcowitz said that he had abandoned the operation on ac- 
count of failures, and said there was also a good theoretical reason 
why this operation should not be done. In some cases the testis are 
fastened to the bottom of the scrotum by the remains of Hunter's 

42 



FAILURES IN BOTTLE OPERATION FOR HYDROCELE 43 

ligament. To perform this operation properly, in such cases, the 
ligament has to be cut. If this has to be done, it is just as easy, or 
easier to cut the sac away, that is, to perform Von Bergmann's oper- 
ation. 

The object in reporting these failures is to emphasize the fact that 
even in selected cases, "the bottle operation" may give as unreliable 
operative results as the allied operations of Doyen, Jaboulay and 
Winklemann. 



INTRADURAL SECTION OF THE SIXTH, SEVENTH, EIGHTH 

AND FIRST DORSAL POSTERIOR NERVE ROOTS FOR 

INTRACTABLE BRACHIAL NEURALGIA— FAILURE 

TO RELIEVE THE PAIN— LATER SECTION OF 

THE CORRESPONDING ANTERIOR ROOTS 

WITH NO RELIEF. 

H. H. M. Lyle, M.D. 

The patient, an engineer, 43 years old, was referred to the service 
of Dr. C. L. Gibson by Dr. W. Bastedo, with a diagnosis of Intractable 
Brachial Neuralgia. Three months previously to admission he was 
violently injured by a lever striking him on left side of his neck at 
the level of his jaw. He was unconscious for 24 hours. The left arm 
was completely paralyzed, and he suffered intense pain in the neck 
and arm. An exploratory incision showed that the roots of the cervi/ 
eal plexus were torn. The arm was amputated. At the present time 
he complains of an intense neuralgic pain in his missing hand and 
arm. 

Physical Examination.— Spare man, aged 43, looks haggard and worn. 
Heart, lungs and abdomen normal. Left pupil contracted and undilatable. 
There is a vertical scar, 2% inches long, at the anterior border of the left 
sterno-mastoid. The left arm has been disarticulated at the shoulder. The 
resultant scar is freely movable and the stump is not sensitive to pressure. 
The bony parts appear to be normal except foi a slight prominence of the 
left clavicle and upper ribs; there is slight lateral curvature of the spine. 
As the arm was missing, no notes regarding anaesthesia are available. The 
patient was examined by Dr. Pierce Bailey, who recommended an unilateral 
intraspinal division of the left 7th and 8th cervical and 1st dorsal posterior 
nerve roots. X-ray examination of spine is negative. 

Operation, December 1, 1910 — Unilateral laminectomy with seetion 
of 6th, 7th, 8th cervical and 1st dorsal posterior nerve roots, by 
Dr. Lyle. 

With the patient in the ventral position, an incision 414 inches 
long was made in the cervical region, the muscles separated and a 

44 



SECTION OF NERVE ROOTS FOR BRACHIAL NEURALGIA 45 

hemisection of the laminae made, according to Taylor's method. The 
dura was then opened, the posterior roots of the last three cervical and 
the first dorsal were identified, hooked up and cut. The posterior root 
of the sixth cervical had been torn away from the cord. The dura was 
sutured with a fine catgut and the wound closed. 

There was a moderate post-operative reaction. The patient re- 
mained free from pain for 5 days, then he began to complain of pain 
in the thumb, hand and arm ; this pain gradually increased, and at the 
end of two months was, if anything, more intense than before the 
operation. 

As an explanation of the failure of posterior root section to cure 
certain cases, it has been stated that there are additional sensory 
paths in the anterior roots, and in such cases, these possible sensory 
paths must be cut in order to obtain a cure. With this point in view, 
Dr. Taylor decided to section the anterior roots. As the arm was 
already gone, this appeared to be an ideal case to try it in. Six 
months after the original operation, Dr. Taylor cut the anterior roots. 
This operation has failed to relieve the pain. 

The points of interest in this case are the tearing away from 
the cord of the posterior root of the sixth cervical, and the persistence 
of the intense pain in the hand and arm after a complete section of 
both the posterior and anterior nerve roots of the 6th, 7th, 8th cervi- 
cal and 1st dorsal. 



GUMMA OF THE LIVEE AS A SEQUEL TO YAWS. 

H. H. M. Lyle, M.D. 

Patient, male, age 49 years, native of West Indies (Grenada). 

Family History.— Father and one uncle died of carcinoma of the stomach. 

Past History.— The patient had had gonorrhoea 15 years ago, and yaws 
(frambesia), 39 years ago. No history of syphilis. Has complained of 
gastric trouble for 30 years, at various times has been treated for gastritis, 
ulcer and carcinoma. 

Present History.— Patient complains of a constant pain in stomach; this 
comes on an hour after eating, and persists until the following meal, or un- 
til relief is obtained by vomiting. The constant pain has kept him awake 
at night. Lately he has noticed a fulness in the upper epigastrium. Is 
weak, and has lost 40 pounds in weight. The blood examination is negative; 
the analysis of the stomach contents shows a hyperacidity. 

Physical Examination. — The patient is greatly emaciated. No glandular 
involvement can be made out. There are several old scars on the arms and 
legs; these are said to be results of yaws. In the midline of the abdomen, 
1 inch below the ensiform cartilage, there is a smooth, hard mass, which 
apparently lies below the edge of the liver. The spleen is not enlarged. 
A preoperative diagnosis of carcinoma of the stomach, starting from an old 
ulcer, was made. 

Operation by Dr. Lyle. 

A smooth, round tumor, the size of a mandarin orange, was found 
on the anterior surface of the left lobe of the liver. The liver was en- 
larged and congested. The stomach, pancreas, and spleen normal, the 
mesenteric glands are not enlarged. As an extended search failed to 
reveal any other lesion, a diagnosis of gumma of the liver was made 
and the abdomen closed. 

Two Wassermann tests were made, the first was negative, the sec- 
ond doubtful. After an intravenous injection of salvarsan, a third 
Wassermann test was made, which was positive. Under specific treat- 
ment, the tumor has disappeared and the liver has grown smaller. 

The interest in this case rests largely on the possible relationship 
between yaws and syphilis. The patient and two other members of 

46 



GUMMA AS A SEQUEL TO TAWS 47 

his family were isolated in a hospital given over to the treatment of 
yaws. Under these circumstances, it is reasonable to assume that 
the diagnosis of yaws was correct. 

It has been said that an attack of yaws gives an immunity to 
syphilis. If this is the case, the patient must have had syphilis before 
yaws. 



CHRONIC PERISIGMOIDITIS WITH PARTIAL VOLVULUS. 

H. H. M. Lyle, M.D. 

The patient, male, 50 years old, has for a considerable time suf- 
fered from attacks of pain and distention in the left iliac region. 
These symptoms have been distinctly localized. The attacks have 
been preceded by severe frontal headaches, and no relief could be 
obtained until the distention was reduced by free bowel movements. 
Two days prior to his admission to the hospital, he had a severe head- 
ache, which compelled him to give up his work. He took a cathartic, 
which set up violent peristalsis, resulting in 10 or 12 movements of 
the bowels. These were at first fecal, but soon became mucoid and 
bloody. Following this, the patient was seized with a violent pain in 
the iliac region, and he vomited several times. With the onset of 
the pain, the movements of the bowels ceased abruptly. No gas was 
passed. 

Physical examination : The patient presents the picture of an acute intes- 
tinal obstruction. There is moderate general distention of the abdomen, with 
marked local distention and tenderness in the left iliac region. The patient's 
temperature is 100, pulse 120. There is moderate leucocytosis, with no relative 
increase in the polymorphonuclears. After lavage and repeated enemata, the 
distention was greatly reduced, and some gas passed per rectum. As the 
symptoms were apparently improving, the operation was deferred, the patient 
meanwhile being kept under close observation. With the reduction of the 
distention a distinct mass was made out, which gave the impression of a thick- 
ened intestine. The most probable diagnosis seemed to be an obstruction from 
a new growth. 

Operation by Dr. Lyle. 

The sigmoid was found to be covered with broad, veil-like adhe- 
sions; the lower edge of this veil was tough and fibrous, and it ex- 
tended from the parietal peritoneum across the sigmoid. Around 
this, as an axis, the sigmoid had partially revolved. The band was 
freed, and the sigmoid straightened out. The presence of the veil- 
like adhesions showed an attempt on the part of Nature to limit 
the greatly dilated and movable sigmoid. 

48 



PERFORATION OP A SIMPLE ULCER OF THE COLON- 
OPERATION. 

H. H. M. Lyle, M.D. 

The caput eoli and the lower portion of the ascending colon can 
be looked upon as the stomach of the large intestine. The functions 
of this segment correspond both embryologically and anatomically to 
those of the true stomach. With these facts in mind, it is not strange 
that similar pathological conditions may occur in this region. 

The occurrence of a simple ulcer of the colon has been known for 
a long time. Cruveilhier (1830-32), in speaking of gastric ulcer, 
wrote, "these considerations apply perfectly to the small and large 
intestine." Unfortunately, Cruveilhier 's clinical examples were not 
well chosen. The discussion aroused by Cruveilhier led to the re- 
porting of a case by Marchesseaux (in 1837) and a second by Roger 
(1838). Lebert (1855-61) stated that simple chronic ulcers are 
analogous in all points to those of the stomach; the latter occurring 
the more frequently, had received the most attention. In 1897, 
Combes reported 2 cases. 

In all these observations not much attention was paid to the clin- 
ical aspect of the subject until 1902, when Quenu and Duval published 
a paper entitled "L 'Ulcere Simple du Gros Intestin." In this mono- 
graph the authors attempted to rescue the simple ulcer from the 
pathological chaos of the large intestine. The paper is a clinical 
study of the pathogenesis, the symptoms, diagnosis, etc., of this little- 
known affection. It is based on personal observations and a study of 
the 31 cases reported in the literature. They state that the simple 
ulcer of the colon has all the pathological characteristics which dis- 
tinguish a "round ulcer" of the stomach from other gastric ulcers; 
it is a simple ulcer in the group of colon ulcerations. Of the 31 re- 
ported cases, 13 occurred in the caecum and ascending colon; in 20 
cases the ulcers were multiple ; 23 cases perforated. 

The following case occurred in the service of Dr. C. L. Gibson, 
and was operated on by Dr. Lyle, October, 1909. 

49 



50 ST. LUKE'S HOSPITAL REPORTS 

Surgical Number 79,130. — The patient, a married woman, 26 years old, 
was admitted to the hospital with a diagnosis of acute gangrenous appendici- 
tis. The patient has been a sufferer from indigestion and chronic constipa- 
tion for years. In her search for relief she has made the rounds of the 
clinics. The obscurity of her symptoms has led to the different diagnoses 
of gall stones, kidney stones, ulcer of the stomach, appendicitis, etc. Lately 
she has complained of a dull, aching pain in the region of McBurney's point ; 
this pain is worse after a full meal and after exercise. Occasionally she has 
had attacks of alternating constipation and diarrhoea. No blood has been 
passed. There is no history of jaundice, typhoid, tuberculosis, or lues. She 
has lost considerable weight and strength. 

Two weeks ago she was seized with a sharp, rumbling, colicky pain 
in right iliac fossa. There was considerable tenderness and distention on 
the right side. The patient was nauseated, but did not vomit. The pain was 
accompanied by a chill and a severe headache. After an hour the pain sub- 
sided, and became intermittent in character, lasting for an hour or so and 
then disappearing. This condition persisted for three days. Just before ad- 
mission she was seized with violent cramplike pain in the right iliac fossa ; 
she was nauseated, and vomited. The pain was accompanied by a severe chill, 
a sense of weakness, and intense tenderness just above the crest of the ileum. 
After an hour the pain subsided somewhat and became intermittent in char- 
acter. Her bowels are constipated. There is an increased frequency of urina- 
tion, but no burning. 

Surgical condition : Woman, small frame, poorly nourished ; heart and 
lungs normal, abdomen slightly distended, no general rigidity, no cutaneous 
hyperesthesia. In the right iliac fossa there is a tender mass about the size 
of a lemon. Vaginal and rectal examinations negative. On admission, patient 
had a subnormal temperature, but just before going to the operating room it 
rose to 100, pulse 92, respiration 26. 

Blood examination : Leucocytes 25,000, polynuclear 86, lymphocytes 14. 
A diagnosis of acute appendicitis, with abscess, was made, and patient sent 
to the operating room. 

Operation by Dr. Lyle, October 23, 1909. 

The abdomen was opened by an intermuscular incision over the 
mass ; on reaching the peritoneum a large abscess containing fecal 
matter was encountered, the cavity was evacuated and a search for 
the appendix was instituted. The appendix was found without the 
mass and apparently had nothing to do with it. On the inner wall 
of abscess cavity there was a moderate-sized perforation of the as- 
cending colon ; the immediate edges of the perforation were formed of 
necrotic mucous membrane. The perforation was found to be in the 
center of an oval, indurated ulcer of the external wall of the ascend- 
ing colon. The greatest length of the ulcer (2y 2 ) lay in the long 
axis of the gut. There was marked involvement of the surrounding 
lymphatic glands. The immediate edges of the ulcer were trimmed 



PERFORATED SIMPLE ULCER OF THE COLON ul 

away and saved for microscopical examination. The ulcer was then 
closed with a double Lembert suture as the induration precluded the 
use of an exulcerating purse-string suture. Contrary to expectation, 
the indurated fibrous tissue offered an excellent hold for the suture 
material and made the closure very simple. As the possibility of a 
lymphatic infection from the appendix could not be excluded, the 
appendix was removed. After inserting a rubber dam drain, the 
wound was closed. The patient made an uninterrupted recovery and 
was discharged from the hospital in 21 days. There was no fecal 
leakage at any time after the operation. The microscopical exami- 
nation showed an edematous mucous membrane with ulceration, no 
evidences of carcinoma or tuberculosis, the appendix was normal. 

The resemblance between this condition and that of a perforating 
gastric ulcer was so striking that one could almost have believed that 
one was dealing with a typical round ulcer. The condition in no way 
resembled the usual ulcerative processes encountered in this region ; 
there were no diverticula of" fecal concretions. 

The patient disappeared from view until March, 1912, when she 
returned with a ventral hernia in the scar of the former operation. 
The hernial repair was performed by Dr. Gibson; and at this oper- 
ation an excellent opportunity was offered to study the condition of 
the colon. 

The second operation for a ventral hernia occurring in the scar 
of the above operation was performed by Dr. Gibson, in March, 1912. 
The colon appeared to be perfectly normal in all respects, and the 
only means of identifying the site of the old ulcer was the presence 
of a few membranous adhesions. 



A SERIES OF CASES OF SURGERY OF THE SMALL 
INTESTINE. 

"W. Scott Schley, M.D. 

The following cases of resection of the intestine, and of obstruction 
without resection, occurred upon the 1st Surgical Division in the 
service of Dr. Abbe. They are a part only of the small intestine 
work, and represent chiefly emergency conditions operated by the 
writer. There are several interesting types of obstructive conditions. 
The fairly numerous cases of strangulated hernias, inguinal, femoral 
and umbilical, have not been included. All of these patients have 
recovered, all have been seen at intervals since leaving the hospital 
(but one), and all remain in good condition. The conditions cited 
below illustrate a variety of troubles, and the operative findings have 
been shown by schematic drawings. 

Case 1. — M. F., a small boy of 12 years, was admitted March 11, 1908. 
Two and one-half hours before entrance, while attempting to climb a wall, 
he pulled down a large stone, and falling backward the rock came down 
upon his abdomen. He was carried home and suffered severe pain from 
the moment of being struck. He vomited brownish fluid resembling "blood 
and dirt" Urination normal after accident ; no blood in urine. 

On admission he was greatly shocked, pale and with cold extremities. 
There were contusions and abrasions of the face, but none of the abdomen, 
which was flat, not distended, but generally rigid, especially the upper half. 
Maximum point of tenderness in epigastrium just to right of median line. 
There was dulness in the flanks, which seemed distinctly to change with 
change of position. The house surgeon noted that the area of dulness 
seemed to have increased in the short time the patient was in the ward be- 
fore operation. It was considered a case of ruptured liver or intestine. 
Operation : Straight incision through right rectus muscle. Abdomen found 
to contain a large amount of bile with considerable blood. Liver and gall- 
bladder and bile-passages found undamaged. Jejunum found torn com- 
pletely across three inches from duodenojejunal junction. Ends of gut 
trimmed and immediately united with small Murphy button, reinforced with 
peritoneal stitch. Recovery uneventful ; button passed before leaving hospital. 

Case 2. — S. McO, a woman of 37 years, was admitted to the hospital, May 
20, 1910. Fifteen years before she had had the ovaries removed, and two 
years later the uterus. Ten years later, following a year of constipation 

52 



SURGERY OF THE SMALL INTESTINE 



53 



V 



V 




Fig. 1 (Case 1). — Rupture of jejunum at transverse double lines. SecoDd 
dotted lines show continuity restored with button. 



54 



ST. LUKES HOSPITAL REPORTS 



with periods of vomiting and difficult micturition, she was operated upon 
again and adhesions were said to be the cause of the trouble. After this 
operation a "lump" api>eared in the scar, and grew for six months, when it 
was excised. It recurred, and was again removed, a year and a half ago. For 
the third time it has appeared and gradually increased in size. Posture, 
she declares, has some effect upon the size. At times it is painful. 




Fig. 2 (Case 2). — Point 1 shows mass in abdominal scar adherent to gut. 
Dotted lines, limit of resection. Point 2, lateral anastomosis. 



SURGERY OF THE SMALL INTESTINE 05 

She presented a mass the size of a golf ball in the abdominal wall near 
lower margin of previous laparotomy scar. The skin was involved and the 
center had an ulcerated area. Probe passed down the center an inch. No 
discharge. The mass did not appear to be tender and was attached to the 
tissues of the abdominal wall. Examined vaginally, no added information 
could be obtained. 

Operation: Old scar, including growth, excised. The mass was found 
densely adherent to a loop of small gut. Malignancy was suggested from the 
history of recurrences, and it was thought wiser to resect the adherent por- 
tion of gut. Four inches of gut were excised and the ends brought together 
by lateral anastomosis (Fig. 2). 

Microscopic examination of the tissue showed chronic inflammation only. 
There was no history of a fecal fistula, wound suppuration, nor was there an 
old stitch. The muscular tissues were not invaded. 

Case 3. — F. F., a woman of 40 years, was admitted to the hospital Novem- 
ber 9. 1910. This patient came seeking relief for a large ventral hernia re- 
sulting from an operation performed two years before for ovarian tumor. 

She presented a long scar to the right side of the mid-line, broad and 
very thin. Skin and thinned-out scar tissue, to which the gut was densely 
adherent and through which the convolutions were visible and palpable, 
alone formed the abdominal wall at that point. 

Operation: Old scar excised. Even with the greatest care a loop of the 
very thin-walled gut, densely adherent to the cicatrix, was opened. The re- 
mainder of the adherent intestine was separated with difficulty, often leaving 
a mass of scar tissue on the bowel wall. The opened knuckle of gut was 
excised and the ends brought together by lateral anastomosis. Recovery 
was uneventful ; highest temperature following operation, 100 1-5°. 

Case 4.— E. H., a woman 42 years of age, entered the hospital April, 1910. 
She had a discharging small intestine fistula in a scar in the mid-line of the 
abdomen. In November, 1909, I had operated in the country upon this pa- 
tient for intestinal obstruction of the most urgent sort. She was then seven 
months pregnant and had been taken six days before with the acute pain, 
vomiting and abdominal cramps of that condition. When seen, her condition 
was desperate, and a hasty operation resulted in freeing a loop of ileum 
from a band just below the pelvic brim on the right side. From the length 
of time the gut had been shut off, it was gangrenous at the point of con- 
striction. Three inches were excised and the ends joined with Murphy but- 
ton reinforced with peritoneal stitch. During convalescence, two weeks later, 
the wound opened and discharge from the small gut took place. The button 
could be felt in the gut and was removed by the attending physician through 
the wound. Several months later she came to the city for the closure of 
the intestinal fistula. At this operation it was found that the button had 
passed down several feet from the original site of resection and had lodged 
in an angle of bowel that had become attached to the median incision. It 
had then ulcerated its way through. The intestine was freed, again resected 
and the ends closed by end to end suture. This patient has been seen re- 
cently and is in perfect health. 



56 



ST. LUKE'S HOSPITAL REPORTS 



Case 5. — M. D., a small girl of six years, was admitted December 7, 1909. 
She bad been taken sick one week before with abdominal pain and vomiting. 
From the onset of pain, the vomiting had been frequent and irrespective of 
attempts to take nourishment. Bowels said to have moved well day after 
beginning of attack and two days before entrance. No blood or unusual 




Fig. 3 (Case 3). — Intestine densely adherent along whole extent of 
abdominal cicatrix. Portion of gut resected with cicatrix and united by 
lateral anastomosis. 



SURGERY OF THE SMALL INTESTINE 



57 



conditions were noted by the parents. The abdomen was not rigid, mod- 
erately distended and with general tenderness. Signs of fluid within the 
peritoneum. Right rectus more rigid than left. Rather more tenderness 
over right lower quadrant and with greater muscular spasm. A mass occu- 




Fig. 4 (Case 4).— Point 1, site of original obstruction. Point 2 (should 
have been descending colon), where button ulcerated through gut and estab- 
lished a fistula. Point 3, where colon was resected and joined by end-to-end 
anastomosis with suture. 



58 ST. LUKE'S HOSPITAL REPORTS 

pied the region of the caput and extended for four or five inches along the 
line of the ascending colon. Rectal examination revealed nothing. 

Operation: Intermuscular incision over caput extended by opening the 
rectus sheath. Condition found to be ileo-colic intussusception with gangrene 
of the small gut. It was so rotten that it was difficult to reduce. The mes- 
entery was black with thrombosed vessels. Over 22 inches of intestine were 
excised and the small gut anastomosed with the caput at the ileo-csecal 
junction by button reinforced with peritoneal stitch. Button passed on 7th 
day. Convalescence stormy and prolonged. Child now in excellent health. 

Case 6.— G. K., a man, 42 years of age, was admitted first to the Medical 
Service of Dr. Janeway, Dec. 23d, 1910. An abdominal condition of gravity was 
certain, but an exact diagnosis could not be made. He had been taken sick 24 
hours before entrance and several hours after a meal, with a sudden sharp pain 
across the upper abdomen. This pain was continuous and frequently radi- 
ated to the lower abdomen in a stab-like manner. He vomited once several 
hours after the beginning of the attack. Bowels have not moved since the 
attack, nor has he passed flatus. Blood count and differential count both 
high. Examination revealed only a moderately distended abdomen with 
general rigidity. Tenderness to pressure was not marked and seemed some- 
what greater over the upper half. Some fluid accumulation. He had the 
appearance of suffering and of one acutely ill. Transferred to Surgical 
Division. 

Operation: Median incision below umbilicus. Large amount of blood- 
stained serum. No odor. Intestine moderately distended and with slight 
vascular engorgement. Twenty-two inches of bowel were found black red 
from occlusion of mesenteric veins. On section, the arteries of the mesentery 
bled freely, but the veins were thrombosed. The diseased gut and liberal 
healthy margins were removed. Ends joined by button reinforced with peri- 
toneal stitch. 

This patient did well, but failed to pass the button before leaving the 
hospital. He returned a month ago for another condition, and the radiograph 
showed that he had passed it in the meantime. 

Case 7.— E. S., a man of 27 years, was admitted April 11, 1911. He had 
been operated upon five months before at the hospital for an acute appendi- 
citis with abscess. He was drained for some time and made a good recovery. 
After being home for some weeks, he began to have occasional attacks of 
colicky pain associated with a sluggish condition of the bowels. The morning 
of his admission to the hospital, for the second time he bad been taken with 
a sudden and very severe pain about the umbilical region accompanied with 
nausea and vomiting. On entrance his appearance was typical of intestinal 
obstruction, and the demand for interference immediate. 

Operation: The abdomen was opened in the median line. 

The adhesions in the right iliac region were very dense and also on the 
right side of the pelvis. In the greatly distended condition of the small gut 
and the mass of adhesions, the particular point of obstruction could not be 
found. An enterostomy was done, taking as low a point in the ileum as 
possible. After drainage of the bowel for several weeks, his condition was 



SURGERY OF THE SMALL INTESTINE 



59 



so greatly improved that the operation for relief of the cause of the obstruc- 
tion could be undertaken with more leisure and deliberation. The area of 
the colostomy wound containing- the gut was excised and the intestine lightly 
clamped off. With considerable difficulty, the small gut was freed from ad- 
hesions and bands throughout and traced down to the caecum and the large 
gut from that point to the rectum. On account of the damaged condition of 
the peritoneal coat from the old inflammatory process, the anastomosis was 
done by invagination (see Fig. 8), after the method described last year by 




Fig. 5 (Case 5). — Gangrenous intussusception. Twenty-two inches of ileum 

resected. 



60 



ST. LUKE'S HOSPITAL REPORTS 



Dr. Gibson in the report, rather than by the more usual one of end to end 
or lateral anastomosis. This man has been seen within a fortnight and is 
well. 

Case 8.— M. H. ( a woman 22 years of age, was admitted January 6, 1911. 
She had been operated upon a year before for an appendicitis with abscess 




Fig. 6 (Case 6). — Mesenteric thrombosis, veuous closure. Resection of nearly 

two feet of gut. 



SURGERY OF THE SMALL INTESTINE 61 

and peritonitis at another hospital. Since that time she has been troubled 
greatly with constipation, getting worse. She has had severe abdominal 
pains accompanied with marked constipation at fairly frequent intervals. 
For a week before entrance her bowels had not moved. Three days before 
admission she was taken with unusually severe pain accompanied with per- 
sistent vomiting. Her distention was great, the vomitus foul and geueral 
condition bad. 

Operation: A dense mass of adhesions occupied the pelvis and the right 
lower quadrant of the abdomen. The exact site of occlusion could not be 
determined in the time allowed for a safe conclusion of the operation. As 
in the former case, an enterostomy was considered preferable to an imme- 
diate anastomosis. A loop of ileum two feet from the caput was brought 
into the median wound, and as in the last case, a rubber drain tube inserted 
proximally. After several weeks of clearing out and drainage, an attempt 
was made to separate adhesions and find the point of occlusion. The density 
and extent of the matting together of the bowel made separation impossible, 
and the only recourse left, to empty the small gut into the large, was ac- 
complished by a direct implantation of the proximal end into the transverse 
colon, the nearest available large gut free from adhesions. The distal end 
was likewise implanted that there might be no excluded or occluded intes- 
tine. It was impossible to resect this distal part on account of the iron- 
clad nature of the adhesions, and at the time no other disposition seemed 
possible. This patient was seen four months after her operation and de- 
clared herself well and comfortable. She had gained greatly in weight and 
appeared in perfect health. 

Case 9.— Intestinal Obstruction from Enterolith: J. K., a man 72 years 
of age, was admitted March 2, 1908. Four days before entering the hospital, 
he was attacked with a dull grinding pain across the upper part of the 
abdomen. He took cathartics without result, nor would enemas relieve him. 
Vomiting occurred two days later, and on admission was of distinctly fecu- 
lent character. It is of interest to note that the patient, a physician and an 
intelligent man, asserts that he had no trouble of any sort with his bowels 
prior to this attack. Two years before he had passed a number of gall- 
stones, the size of distal joint of index finger, and which had facets. Before 
their passage he had attacks of gall-stone colic. 

Operation: Incision through the right rectus disclosed a collapsed large 
gut with a distended small gut. On working back from the ileo-ca?cai junc- 
tion a large, smooth, dark mass was found distending the lower part of 
the jejunum. It could not be moved up or down. An incision opposite the 
mesentery released a stone the size of a small hen's egg. There was no ul- 
ceration of the mucosa of the intestine; there were no diverticula in which 
the stone could have pocketed. The convalescence of this elderly patient was 
uninterrupted. 



62 



ST. LUKE'S HOSPITAL REPORTS 




Fig. 7 (Case 7).— Intestinal obstruction following suppurative appendi- 
citis. Numerous and deqse adhesions. Enterostomy followed later by freeing 
adhesions, use of sterile oil and anastomosis by invagination (see Fig. 8). 



SURGERY OF THE SMALL INTESTINE 



63 




Fig. 8. — Anastomosis in case 7, by invagination. 



64 



ST. LUKE'S HOSPITAL REPORTS 




Fig. 9 (Case 8). — Intestinal obstruction following suppurative appendicitis. 
Dense adhesions, enterostomy, later implantation into colon (see Fig. 10). 



SURGERY OF THE SMALL INTESTINE 




Fig. 10 (Case 8). — Impossible to separate adhesions. Both distal end and 
proximal implanted into nearest free colon (transverse). 



66 



ST. LUKE'S HOSPITAL REPORTS 




Fig. 11 (Case 9).— Buterolith impacted in lower ileum. Complete obstruction. 



SURGERY OF THE SMALL INTESTINE 



G7 




Fig. 12 (Case 10). — Enterolith impacted in lower ileum. Complete obstruction. 



GS 



ST. LUKE'S HOSPITAL REPORTS 







Fig. 13 (Case 11). — Acute obstruction caused by augulated ileum adherent to 
caseous mesenteric gland. 



SURGERY OF THE SMALL INTESTINE GO 

Case 10.— Intestinal Obstruction from Enterolith: A. H., a woman of 60 
years, was admitted to the hospital April 5, 1908. She had been taken with 
nausea and vomiting five days prior to her entrance. The vomiting was 
continuous, and she could not retain food or medicine on her stomach. First 
food, then bile, then feculent material came up. Vomiting gave relief. This pa- 
tient says that she has never been jaundiced and that her bowels have 
always been regular. Her general health has always been good. She has 
had no serious illnesses in the past. She was very ill on entrance with 
greatly distended abdomen and dry tongue. 

Operation: Median incision. Large intestine collapsed and small dis- 
tended. On working back from the caput cob, a dark mass the size of a 
pullet's egg was found distending the gut about 18 inches from the ileo-caeeal 
valve. The intestinal wall was very thin and distended, but it was possible 
to push the stone up to a higher level where the thinning was not so marked, 
and remove it through an enterotomy at that point where repair by suture 
would be easier. As in the former case, there was no ulceration of the 
intestinal mucosa, nor were there diverticula to be seen. Convalescence here 
also was most happy. Both of these cases have been followed, and they 
are apparently in excellent health to-day. 

Case 11.— I. T., a small boy in his 9th year, was admitted April 24, 1907. 
He had been well the earlier years of his life, but for some time before 
present illness had had occasional abdominal cramps. He was taken three 
days before admission with severe cramps in the abdomen and vomiting. 
Bowels moved slightly during the interval before admission. The boy ap- 
peared to be a well-nourished child. The abdomen was greatly distended 
and very tender over the whole surface. Peristalsis could be easily seen. 

Operation: Median Incision, umbilicus to pubes. Large gut collapsed. 
Small gut distended and deeply injected. The cause of the obstruction wag 
found to be an adhesion about one-quarter of an inch in diameter, extend- 
ing from an enlarged old lymphatic gland, near the foot of the mesentery, 
to the ileum two inches from the caput coll. The obstruction had been 
caused by the angulation and constriction. The gut was viable and its re- 
lease was accomplished by cutting the band. This patient made a rapid 
recovery and has been seen several times since leaving the hospital. 



SIMPLIFIED EQUIPMENT AND MANAGEMENT FOR THE 
OPERATING ROOM.* 

W. Scott Schley, M.D. 

The natural tendency in matters relating to surgical operative 
equipment is rather towards elaboration and addition, as new facts are 
discovered and newer requirements develop in the steady, march of 
progress. The endeavor to have every added essential and accessory 
immediately to hand is the most fruitful source of complication and 
elaboration, requiring a very constant attention and study to elimi- 
nate and simplify, as the burden of paraphernalia becomes unneces- 
sarily irksome, time-consuming and possibly wasteful. 

In operative work a proper economy of time and labor should not 
be lost sight of, especially when it results in greater good to the pa- 
tient, greater surety and ease, and a greater saving of materials. 
These things can best be accomplished by a safe and quick method 
of handling gauzes, instruments and solutions, the ready accessibility 
of everything needed, and excellent lighting, making it possible for 
sterile individuals to conduct the entire work rapidly and without 
danger of rendering themselves or the material unsterile at any 
stage. 

There is nearly always something in other plants and equipments 
of actual or suggestive value that well repays time spent in study 
and observation, for comparison with and often the elucidation of 
problems at home. From time to time additions and changes in the 
operative equipment at St. Luke's Hospital, New York City, have 
been made whenever greater ease and surety of work and a greater 
saving of time, materials and general labor to all could be gained. 
These objects have never been lost sight of, and to-day the equip- 
ment stands, I believe, second to none in simplicity and working ef- 
ficiency. The constant endeavor of those interested in these things 
has been towards elimination and simplification of existing material 
and its concentration, rather than the addition of more: the perfection 
of essentials and rejection of unessentials. 



*Previoii8ly published. 

70 




Fig. 1. — Showing instrument sterilizer open. High-pres- 
sure steam pipes under the flooring, and entering the sterilizer 
from helow. 



SIMPLIFIED EQUIPMENT FOR OPERATING ROOM 71 

The general requirements, which have become recognized through 
study, observation and experience, will first be mentioned, and then 
spoken of more in detail. 

The operating room should be of fair size and self-contained, the 
necessary equipment being within the room itself or in its walls, to 
the saving of many steps and the unnecessary passing of assistants 
and nurses in and out during the progress of operative work. The 
furniture can be so reduced and simplified that nothing but the oper- 
ating table, instrument table, canisters for holding gauzes and dra- 
peries and an electric towel heater occupy the free floor space ; hot 
and cold water sterilizer or its taps, instrument and utensil sterilizers 
and the few solution bottles being arranged along or even within re- 
cesses in the walls. Instrument cases are best built in the walls with 
glass doors flush with the wall, eliminating movable and obstructing 
furniture and dust accumulations. If two operating rooms adjoin, 
they can be accessible from either side. An excellent example of this 
was seen at Sonnenburg's Clinic at the Moabit Hospital, Berlin. 
Special solutions, anesthetics, hypodermatic solutions, etc., are best 
arranged similarly. Instrument and utensil sterilizers should be 
actuated by high pressure steam coil and should be opened by foot 
pedal, enabling sterile assistants or nurses to operate them without 
hand contamination or the necessity of calling others to aid. Stock 
solution bottles (saline, alcohol and sublimate), and the hot and cold 
sterile water taps should be also arranged for foot release. It is 
possible by such means to cut down the personnel of the operating 
staff, and especially to avoid the intermediary handling and exposure 
of gauzes, drapery and instruments in transit from the sterilizer to 
the operating table. 

Natural lighting, as long recognized, should be from one side of 
the room as well as from above. Artificial lighting is best accom- 
plished by means of the newer indoor enclosed electric arc, both for 
general illumination and for direct lighting above the table. 

A means that will provide perfect protection for gauzes and 
drapery and yet allow of instant accessibility was found in Europe 
and brought to a high state of perfection by von Biselsburg, of Vienna, 
in the canister container system. Gauzes are sterilized in closed metal 
canisters and their air ports closed. They are then ready at any time 
to be brought in and placed on the stands where the cover in a few 
seconds is connected with the cover-elevating device worked by foot 
lever. They are always handy, their contents are instantly accessible 



72 ST. LUKE'S HOSPITAL REPORTS 

and entirely protected and they can be renewed on their stands, when 
empty, in a few seconds as cartridges in a gun. Experience has shown 
to date no quicker and safer way of handling gauzes, towels and 
drapery. Gauzes may be taken out in small amounts at a time in 
anticipation of their need, by a nurse or assistant, and with the 
gloved sterile hand or forceps. These containers were introduced in 
St. Luke's Hospital in 1905 by Dr. H. H. M. Lyle, have amply proven 
their worth and are used upon both surgical divisions. 

The instrument sterilizer, in addition to being placed in the oper- 
ating room, should not be too far from the instrument passer's table. 
It should be a semi-automatic affair, opening by foot lever and clos- 
ing noiselessly when the pressure of the foot is released. A high pres- 
sure steam coil in the bottom will boil water more quickly than will 
gas. The instruments should be placed in and sterilized in trays, 
and passed from them to the operating table. The present instrument 
was worked out by the author while abroad, and later made in this 
country by one of the large manufacturing firms. This apparatus has 
been placed in the amphitheater of the hospital and has worked with 
efficiency for over three years. It is heated by steam coil from the high 
pressure service of the operating and sterilizing rooms, and will boil 
warm water in 3 minutes. It is placed upon the instrument passer's 
side and but 8 feet from his table, so that he is enabled, unassisted, 
to boil instruments between and during operations, without crossing 
the path of any one, quickly and without contamination of hands or 
instruments. This sterilizer is placed against the wall and does 
not occupy the free floor space. The steam is under complete control 
and the inlet valve can be turned by foot. 

The instruments are placed in shallow copper trays that fit the 
sterilizer and are put in one over the other. A slightly inturned 
edge prevents telescoping and perforated bottoms allow the water to 
drain off on lifting them out. 

Through forethought in construction the amphitheater was pro- 
vided with hot and cold sterile running water, the tanks being be- 
hind the scenes, out of the way, and the taps leading through the 
partition to within a few feet of the operating table. A utensil 
sterilizer also actuated by high pressure steam and operated by foot 
pedal, has been added and placed to the rear, where it is accessible 
and allows the few basins and irrigators used to be boiled between or 
during operations as necessary. 

The operating table is simple and provides the different positions 




Fig. 4. — Copper canisters t'<»r gauzes and draperies. Canister stand with mov- 
able balance weight for cover. 




Difriia"a ii Mi , fi'y 



■Sllll 

liiiMi 

-. T ;.- gg g._ - r5 k, - } £ ■ ■ 81 ■ ■ ■ M 

wsvKssav 
« a! m m m m m mm 

Fig. 5. — Instrument trays. The larger ones have perforated bottoms, and the 

smaller, for finer instruments, are perforated at the edges. 



mmmmmmmui 
•■■mill 
■iiiiaiii 

■■■••■laiBi wng 

■■ lU tii! 








Fig. G. — A battery of canister containers, with towel heater and instrument 

table. 



SIMPLIFIED EQUIPMENT FOR OPERATING ROOM TS 

quickly. The instrument table is a simple glass or metal top affair 
with one shelf below and with a basin bracket on one leg. A table 40 
x 20 inches and 4 feet in height is sufficiently large for general work. 
These two articles of furniture need no elaboration beyond the pos- 
sible addition of a removable stout wire bracket attached to one leg 
to hold a basin of saline solution. 

All solutions except the 10 per cent saline, 70 per cent alcohol and 
1-8 bichlorid of mercury, have been banished from the operating 
room, and these are contained in large stock bottles whose outpour is 
regulated by foot pedal release, and which are placed against the 
wall upon the nurse's side, about 8 feet from the operating table and 
instantly accessible. The proper amount of saline solution is run 
into the small basin or irrigator and sterile water of the desired tem- 
perature is added from the wall taps. Saline or other solutions can 
be made up in this way and reach the operating table in 10 seconds 
without hand soiling. Irrigating stands and large irrigators are not 
used; a 4-quart enameled metal container with 4 feet of tubing an- 
swers all purposes, can be easily sterilized and is held by hand when 
needed. 

For artificial illumination the superiority of the electric arc over 
the incandescent bulb, both for general and direct light, I believe 
is fully apparent when once tried. It gives infinitely more and better 
quality of light. Some of the better equipped European clinics have 
adopted the system with excellent results. Abroad the lights are 
sometimes arranged with upward reflection, which is the best plan 
for general illumination where the walls do not exceed 12 feet in 
height. In the amphitheater at the hospital, where greater height had 
to be dealt with, it was necessary to find a lamp of suitable down- 
ward reflection and diffusion. Such a lamp it was my fortune to find 
in the newer indoor enclosed arc with small opalescent globe and 
thin white porcelain reflector and diffuser above. This lamp is seen 
in Figure 7, where two of these for general illumination take the places 
of batteries of incandescent globes. After some experimentation with 
the lights and shadows of the arc lamp, I devised the apparatus shown 
herewith for 2 lights, with common reflector arranged 4^ feet be- 
tween carbons, that will illuminate the whole table at once in addition 
to the field of operation. 

The small opalescent globe softens and diffuses the 1,200 or more 
candle-power and with the superior regulating device of this lamp 
upon a good circuit and with soft core carbons it is almost absolutely 



74 ST. LUKE'S HOSPITAL REPORTS 

without flicker. These arc lights are arranged as in incandescent 
lighting, and use the same current (taking the 110 or 220 volt direct 
or alternating, and from 3.5 to 5.5 amperes, according to require- 
ment). They are best arranged upon different circuits to avoid the 
possible chance of simultaneous extinguishment should anything hap- 
pen to one circuit. 

For miniature lamps, head lights, cystoscopes, motors, etc., several 
ordinary wall taps have been placed within a few feet of the operating 
table and electrical connection can be instantly made by the ordinary 
push plug. 

More and more it is found that elaborate equipment for general 
operative work, whether of elaborate tables or special instrument 
stands, is not required. In addition to the solution bottles upon the 
nurse's side, there is only a small glass wall-shelf for the few sterile 
basins and the irrigator. 

Upon the First Division the patients are fully prepared in the 
ward and are given only a light alcohol (70 per cent) rub on the 
table as a final preparation after removal of the light sterile protec- 
tive dressing. Elaborate and excessive drapery has been abolished 
and a maximum of 2 sheets, over rubbers, and 4 towels answer for 
the majority of cases. 

In preparing such a room for work but one unsterile person is 
necessary to bring in the 3 canisters and towel heater, place them on 
the stands and connect the covers with the elevating device. The 
instrument passer, before washing up, places the instruments in the 
trays and puts them in the sterilizer. One nurse, before washing up, 
places the few basins and the irrigator in the utensil sterilizer. The 
operator, assistants and other nurses are in the meantime washing 
up and dressing, and the patient is being anesthetized. Hot and cold 
sterile water and the few solutions are always ready. The instrument 
passer, after washing up, covers the top and shelf of the instrument 
table with a few sterile towels from a canister, and removes his trays 
and instruments from boiler to the table. A nurse, upon the nurse's 
side, after washing up, covers the nurse's shelf with towels and the 
small solution basins and irrigator are placed thereon. The unsterile 
orderly or assistant places the suture and ligature containers on the 
lower shelf of the instrument table and the instrument passer takes 
his suture and ligature material, catgut, silk on spools and any other 
material needed for one or two cases and places it in the folds of a 
sterile towel or two. Any suture or ligature material left over, even 




Fig. 7. — Type of stand for stock solution bottles, having foot 
release. 




Fig. 8. — Two lamps with common reflector, 4 feet 6 inches between 
carbons. Apparatus over operating table. Almost complete elimination of 
shadows is produced. 



SIMPLIFIED EQUIPMENT FOR OPERATING ROOM 75 

if contaminated, including the iodine catgut, can be easily and quickly 
resterilized for subsequent days. Anything needed, not anticipated 
in advance, is immediately accessible. 

A perfect division of labor with simplification of apparatus allows 
quicker handling of cases as well as celerity and ease in the prepa- 
ration of the room, and a diminished number of helpers, if preferred. 
All sterilized and necessary materials are accessible to sterile hands 
and but one unsterile assistant is required to handle unsterile material, 
to clean up between cases and do the heavier work. Dry sterile rub- 
ber gloves are worn by all and are always accessible near the instru- 
ment sterilizer in a container opening by foot pedal. 

Such are the main features and outline of the scheme it has been 
the endeavor to instal and perfect at St. Luke's. 

The system works out to include in its personnel the undergraduate 
nurses of the hospital, so necessary in the American plan of educating 
and preparing them for future surgical usefulness in their private 
and institutional work and in rounding out their education. Slight 
modification of duties of the different members of the operating staff 
are therefore undertaken from time to time. 

The suggestions for some of the equipment were gathered at a 
number of the clinics of the world, some of the most valuable from 
the rooms of Eiselsburg, of Vienna ; Kocher, of Bern ; Sonnenburg, of 
Berlin. Thought and experience have added from time to time new 
features to a constant betterment, and through the liberal and pro- 
gressive spirit of the Board of Managers and Superintendent these 
changes have been quickly consummated. 

Because many have been interested in this equipment, and have 
adopted these ideas, and because of the inquiries received, it has 
seemed of sufficient general interest and importance to merit this brief 
article which, leaving the description of mechanical details to photo- 
graphs, is meant to be suggestive rather than complete and exhaustive. 

The canisters were made by one of the larger instrument firms 
and have already been adopted in several hospitals, and recently for 
naval use. The instrument sterilizer was made by another of the 
larger firms and is now manufactured in various forms as regular 
equipment. 



EXTRUSION OF MEDULLARY BONE SPLINT. 
W. Scott Schley, M.D. 

J. S.. a man of 45 years of age, was admitted to the 1st Surgical Di- 
vision May 27, 1911. 

Three years before he had suffered a compound fracture of the left fe- 
mur in the middle third. He was taken to a hospital, where an operation 
was finally done, and after 7 months, he left with the wound completely 
healed. Four months before he entered St Luke's, he noticed a swelling 
on the anterior aspect of the left thigh. This broke down, opened, and left 
a small, discharging wound. He suffered from the suppurating process and 
had temperature and malaise. Two weeks before coming to the hospital, 
another swelling appeared on the outer side of the leg in the old scar. This 
was incised by his physician. Both sinuses led to bare bone at the same 
point on the shaft. The left leg showed 3 inches shortening. 

Operation.— Incision through old scar on the outer side of leg down to 
the bone showed a hard white object projecting from the shaft (see Fig. 1). 
It was thought to be a sequestrum, at first sight. A better view showed that 
it was a bone tube, and by cutting about the shaft and rotating the tube, it 
could be withdrawn. 

The splint had not been absorbed, and had even preserved its surface 
polish. It had finally acted as a foreign body and had been partly expelled. 
It is of interest in connection with the operative treatment of fractures. 



76 




Fig. 1. — Bone splint working 
toward surface. Sinus, discharg- 
ing pus, leads to site. 



TWO CASES OF STONE IN THE URETER. 

W. Scott Schley, M.D. 

Among the eases of kidney and ureter troubles the past year, upon 
the 1st Surgical Division, there have been two of special interest; 
one, because of the great severity of the subjective symptoms with 
the minimum amount of damage, and the other because of the almost 
total absence of subjective symptoms with great and extensive dam- 
age to the kidney and ureter. 

Case I.— J. O. B., male. Admitted June 21. Discharged July 23 last. 
A year prior to entrance he was taken with an exceedingly severe pain in 
the left flank. This pain extended down the left side into the testicle and 
down the left thigh, and was characteristic in its sharp and cutting char- 
acter. This condition was intermittent, hut he was never free enough from 
it to return to work for over 2 months. There have been recurring attacks 
up to the present time. On entrance, he had been having pain more or less 
continuously for 2 weeks. He is said to have passed blood in the urine from 
time to time. He was a well-built and nourished young man, with slight 
rigidity on the left side of the abdomen and left flank without great tender- 
ness. 

Cystoscopy and catherization of the ureters, as well as a radiograph, 
demonstrated a calculus in the lower part of the left ureter 3% to 4 inches 
from the bladder. Little or no urine from affected side. Examination for 
blood on entrance, neg. 

Operation (Dr. Schley).— Transperitoneal ureterotomy. Abdomen opened 
with 6-inch incision through the left rectus. Stone could be felt in the ureter. 
Field of operation padded off and the peritoneum incised, when ureter could 
be drawn up and opened (See Figs. 1 and 2). Stone removed and small 
bougie passed to bladder and pelvis of kidney. Ureter closed with fine in- 
terrupted silk stitches. Peritoneum over ureter closed, leaving a very fine 
cigarette drain just through. Abdominal wound closed in usual way by 
layer suture. 

The convalescence in this case was absolutely uneventful and rapid. 

Case II.— M. Z., female. Admitted April 4, 1911. Discharged May 10, 1911. 
For tbe last 2 years the patient has had a dragging sensation in the right side 
of the abdomen, but hardly amounting to pain. It has never been sufficiently 
bad to prevent her following her occupation as cook. There is no history 
whatever suggestive of attacks of renal colic and none positive of renal 
derangement. 

78 




Fig. 1. — Peritoneum opened. Ureter, containing calculus, drawn out. 




Fi S- 2.— Peritoneum and ureter opened. Calculus tightly wedged in place. 



STONE IN THE URETER 




Fig- 3. — Large hydronephrotic kidney mass. Somewhat lower, and more 
across median line than shown. 



80 ST. LUKE'S HOSPITAL RBPORT9 

She was a fairly well-nourished female of good color to skin and mucous 
membranes. There was no rigidity of the abdominal muscles, and but slight 
tenderness over the right side of abdomen. There was a large, tense, 
elastic mass extending from the free border of the ribs to the pelvic brim 
and across the median line (See Fig. 3). This mass was dull on percussion, 
slightly movable, and not of especial tenderness on deep palpation. It pro- 
duced a very appreciable distention of the abdomen. Vaginal examination 
gave the sense of an indefinite mass high up on the right side. Colonic 
inflation and the position of the mass left no doubt of the condition as a 
kidney tumor. This patient's condition before entrance was diagnosed as 
ovarian cyst and her reason for consulting a physician was as much because 
of her increase in girth as because of the discomfort in the side. 

Operation (Dr. Schley).— Incision through outer border of the right rectus. 
Large, dark, elastic mass with colon running over upper part. Extended 
from behind lower ribs to pelvis. The ureter was greatly dilated, to quite 
an inch in diameter through greater part of its course. Condition plainly 
one of hydronephrosis. Passing a bougie through opening in the ureter 
demonstrated a stone about 2% inches from the bladder, but so rough and 
embedded in the greatly thickened ureter that it could not be dislodged, and 
a 2-stage operation was considered wiser and safer. The kidney, of which 
but a mere shell of tissue remained, was removed and the ureter excised 
to within a few inches of the stone. This patient made so perfect a con- 
valescence and felt so well that she preferred to retain the calculus, and 
operation for its removal was not insisted upon. She has been followed, and 
remains in good health. Microscopic examination of a small remnant of 
cortical tissue near the fundus showed swollen glomeruli and marked paren- 
chymatous degeneration of the convoluted tubules. Radiograph showed the 
calculus near the bladder (Fig. 4). Two photographs show the conditioa of 
the kidney (Figs. 5 and 6). 



Fig. 4. — Stone in lower part of right ureter. 




Fig. 5. — Reduced picture of kidney exterior. Specimen 
was put in strong formalin, without previous distention, and 
great shrinkage resulted. 



**^ 



r 








Fig. 6. — Thin shell of cortex at upper pole can be seen. Typical 
hydronephrosis of extreme degree. 



TUBERCULOUS PERITONITIS SIMULATING RECURRING 
ATTACKS OF APPENDICITIS. 

W. Scott Schley, M.D. 

H. Le V., a young man of 19 years, was admitted to the hospital De- 
cember 27, 1911. His chief complaint was pain in the right lower quadrant 
of the abdomen. 

Family History.— Both parents alive and well. 

Two years ago he had some cough and expectoration and was told that 
he had trouble at the left apex. He left work, lived in the country, and 
apparently recovered. About 8 months ago he began to be troubled with 
stomach disturbances, gas and gurgling, but did not lose weight. Three 
months before coming to the hospital, and while working, he was taken with 
a severe epigastric pain, but managed to finish his work, and the pain had 
gone by night. There was no nausea with the attack. Six weeks later 
had a similar seizure, the pain lasting some 8 hours and extending from 
epigastrium to right lower quadrant. He felt uneasy and tired before the 
pain began. Two weeks before entrance he had his last attack, with pain 
chiefly of the right lower quadrant. There was nausea and vomiting and 
the duration 12 hours. He had been constipated prior to the attack. He 
was seen by a physician at this time, and the diagnosis of appendicitis 
made. He has had some soreness in the right lower quadrant since his 
first attack, and said that he had occasional twinges of pain in the right side. 

His general appearance was that of a well-nourished, well-muscled and 
healthy-looking young man. In the chest a few suberepitant rales could be 
heard at the right apex behind. Thorax expanded well and equally on both 
sides, resonance good. Heart somewhat irregular, 56 per minute on exami- 
nation. Sounds clear and strong. Slight blowing systolic murmur heard 
all over chest, and loudest at apex. There was no rigidity to the abdomen 
or mass felt. Slight tenderness existed in a small area just to right and 
below umbilicus. Superficial glands were not appreciably enlarged, with the 
possible exception of the right epitrochlear. His temperature on admission 
was 97 3 a, and on discharge 98. Beyond a slight reaction to 100 4 / 5 following 
operation, he -had no temperature at all. His pulse ran a fairly regular rate, 
averaging in the seventies. 

Operation.— Intermuscular appendix incision. Scattered over the peri- 
toneal surfaces were numerous discrete pearly nodules varying in size from 
a pin point to a pin head. They were more numerous in the mesentery of 
the appendix than elsewhere, and became much more scattered as one left 
that region. All the loops of ileum drawn down into the wound showed 

81 



8*2 ST. LUKE'S HOSPITAL REPORTS 

tubercles. They were more numerous upou the visceral than upon the 
parietal peritoneum. No adhesions could be demonstrated. The serous 
surfaces were moist, but there was no fluid. The appendix lay below caput, 
towards pelvic brim. It was but moderately congested, and had but a mod- 
erate number of tubercles on the surface, (See Fig. 1.) The presence of so 
many in the mesentery was thought to possibly indicate ulceration of the 
mucosa, and it was removed. It lay free and there were no adhesions. Grossly, 
the appendix showed only moderate thickening of its coats. The internal cali- 
ber was even throughout, and there were no constrictions. It was empty. Sev- 
eral hemorrhagic spots in the mucosa, without apparent ulceration, appeared. 
They were on the side of the mesenteric attachment. The pathological re- 
port shows: Chronic appendicitis. Tuberculous peri-appendicitis invading 
the meso-appendir. 




Fig. 1. — Tuberculous periappendicitis. Numerous tubercles in peritoneal, 
investment of appendix and in its mesentery. 



THE GATCH BED IN SURGICAL WORK. 

W. Scott Schley, M.D. 

For nearly a year, in the male surgical ward of the 1st Division, 
we have been trying a bed that has proved a great success. In ad- 
dition to the usual spring bed, it is intended to provide for an easy, 
comfortable and secure sitting or semi-recumbent position. It has 
served especially well in those abdominal cases for which elevated 
posture is necessary to facilitate drainage, prevent dissemination of 
exudates, or for other reasons. Its great advantage over the back- 




Fig. 1. — Gatch bed in profile. Ratchet ou frame provides for a variety of 
angles of elevation, both for back aud legs. 



rests of various forms lies not only in the fact of the inclined planes 
being integral with the bed itself, but in its taking care of the lower 
extremity as well. This bed was devised by Dr. Gatch, of the Johns 
Hopkins Hospital, and the first one was made up in that institution 
about 2 years ago. The adjustable spring is now made up to fit any 
single bed, and its usefulness is thereby greatly extended, as it can be 

83 



84 



ST. LUKE'S HOSPITAL REPORTS 



adapted to beds in a ward without changing their uniformity. The 
uprights of the regular bed have also recently been fitted with sockets 
for securing two levels for the mattress; a high surgical bed or a 
lower convalescent bed. The ordinary ward mattress takes the angles 
made by the elevation of the spring planes, and a comfortable curve 
is the result that can be borne for long periods. (Figs. 1 and 2.) 




Fig. 2. — Gatch bed, with dimensions in inches. 



SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS.* 
John Douglas, M.D. 

Subphrenic abscess occurs as a complication of acute appendicitis 
in between .5 and 1 per cent of the cases, according to Ross (Journal 
A. M. A., August 12, 1911), who has analyzed the reports of a large 
number of statistics by Treves, Kelly and Hurdon, by Lance, and 
also 3,891 cases of acute appendicitis occurring in the German Hos- 
pital and Mary J. Drexel Home, Philadelphia, Pa. In the 31 cases 
reported by him, there were 22 deaths. Of the 31 cases, from brief 
history reports, it would appear that in 15 the abscess was situated 
below the liver. In the remaining 16, where the pus was between the 
liver and the diaphragm, or above the lower surface of the liver, there 
were only 4 recoveries. 

The following two quotations from Ross' article prompt the report 
of this case with the X-ray photograph, illustrating its value as a means 
of diagnosis : " It is to my mind a refinement of diagnosis at present 
impracticable of accomplishment for any one to determine definitely 
the variety of subphrenic abscess before operation. As will be seen 
later, we are fortunate, indeed, always to diagnose even the existence 
of a subphrenic abscess." Later on, he states: "Only the most care- 
ful study of individual cases will give even an approach to correct 
diagnosis. ' ' 

Grace S., aged 13. Seen in consultation, July 31, 1911. Her illness began 
11 days before, witb an attack of severe vomiting, which lasted iy 2 days, when 
she began to have severe pain in the right side of the abdomen. The pain 
was severe, and aching in character, continuous, not localized, and radiated 
to the back and right shoulder. It was increased by respiration. The pain 
had been gradually decreasing, and was now most marked over the lower 
right chest, in the axillary line. She had fever (103° to 104° F.) every eve- 
ning, but no chills. Has had some cough, but no expectoration. Was slightly 
jaundiced for three or four days, but jaundice had disappeared when she 
was seen by the writer. The bowels had moved every day. 



♦Reprinted from "Surgery, Gynecology and Obstetrics." 

85 



86 ST. LUKE'S HOSPITAL REPORTS 

Physical examination of the chest showed slightly diminished expansion 
and breath sounds, slight dulness, and a few large, moist rales over the right 
base. 

There was no general abdominal rigidity or tenderness, but over the upper 
right quadrant of the abdomen rigidity and tenderness were marked. A mass, 
apparently the lower border of the liver, could be felt 2 inches below the 
costal arch. This area, and just below it, were very tender. Percussion in 
the right mammary line was flat from the fifth intercostal space down to the 
edge of the mass. There was some tenderness in the right costo-vertebral 
angle. The temperature was 103° F., pulse 140, respiration 30. The leucocyte 
count was 25,000, with S8 per cent of polynuclear cells. 

A diagnosis of high appendicular abscess was made, and she was referred 
to St. Luke's Hospital for operation. 

Operation. — An incision 3% inches long was made along the border of the 
right rectus muscle, with its lower end about on a level with the umbilicus. 
The appendix was found with its outer extremity almost sloughed away, 
behind a high, undescended caecum, just underneath the liver. There was a 
small amount of pus, with the characteristic odor of colon infection, well 
walled off from the rest of the peritoneal cavity by adhesions and the omen- 
tum, and limited above by the under surface of the liver. The appendix was 
removed. The liver had been apparently displaced downward, and examina- 
tion demonstrated adhesions between the diaphragm and the upper surface 
of the right lobe. On separating these adhesions a considerable quantity 
of bloody pus, smelling of colon infection, was discharged. A thick rubber 
dam drain was passed up a distance of 12 cm. between the liver and dia- 
phragm, and a counter drainage opening made in the loin. The final incision 
was partly closed, and drained with a rubber dam drain. 

For a week following the operation there was a profuse discharge of 
bloody, purulent material, which gradually became less, but the patient con- 
tinued to have an irregular temperature — up to 101° to 102° in the after- 
noon — the cough became more troublesome, while the physical signs persisted. 
It was believed that the subphrenic abscess was not draining, so to determine 
this fact the X-ray shown in the illustration (Fig. 1) was taken. This 
demonstrated very plainly that the diaphragm, above the liver, was pushed 
upward almost to a point to the level of the eighth rib behind. So an anaes- 
thetic was administered on August 11th, the eleventh day after operation, and a 

'long, soft rubber tube, 1 cm. in diameter, was inserted, to replace the rubber 

.dam, with a further evacuation of pus. The cavity was irrigated through this 
rubber tube, and drainage was again profuse. On August 21st a second X-ray 

•was taken, showing the diaphragm considerably lower; the tube was removed, 
and again replaced by rubber dam. The temperature stayed down for four 

•days, but on August 27th rose to 103° again. 

Under light chloroform anaesthesia, the adhesion between the right lobe 
of the liver and the diaphragm were broken up by the finger, inserted through 
the incision in the loin, with the resulting escape of considerable pus. A 
11 cm. rubber tube was introduced a distance of 12 cm., and the cavity, wbich 
was well walled off, irrigated. 

As the adhesions were quite dense, the question arose whether the dia- 




Fig. 1. — Showing diaphragm displaced upward by abscess. 



SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS 87 

pbragm had been perforated, with involvement of the pleural cavity, and a 
third plate (Fig. 2) was taken, which demonstrated that the end of the tube 
was below the diaphragm. The following day the temperature was normal, 
and further recovery was uneventful. 

It is also of interest in this case to note the presence of jaundice as 
Besredka (quoted by Ross) states, as a means of differential diag- 
nosis ''there is never jaundice in uncomplicated subphrenic ab- 
scesses. ' ' 

The mortality of subphrenic abscess is about 33 per cent. It is 
lower in children than in adults, probably because the large majority 
of eases are due to appendicitis, while in adults a considerable num- 
ber of cases are caused by perforation of the stomach or duodenum. 
Intrathoracic complications have been estimated to be present in 66 
per cent of the cases. This is probably too high, as Ross states that of 
21 cases coming to autopsy, only 5 showed purulent pleurisy and 1 a 
pleurisy with exudate not purulent. Intraperitoneal abscesses, which 
are more frequent, are more apt to perforate the diaphragm than 
extraperitoneal. 

The diagnosis is difficult. In addition to the quotation from Ross 
given above, Reeve (American Practice of Surgery, Vol. 7, 1910, p. 
487) says: "There are no certain physical signs by which in all cases 
collections of fluids above the diaphragm can be distinguished from 
those situated below this structure. ' ' Also, " It is not possible to make 
a differential diagnosis between a subphrenic abscess and an encap- 
sulated basal empyema." He advises, however, the use of the Roent- 
gen rays, and mentions a case in which Monro demonstrated the 
presence of subphrenic abscess by the X-ray after rib resection and 
several punctures had failed. Although writers on the subject allude 
to the unreliability of the physical signs, this case of Monro's was 
the only one found by the writer in which the X-ray as a means of 
diagnosis was made use of. 

The physical signs usually found are dulness or flatness, dimin- 
ished breath and voice sounds and vocal fremitus, with the presence 
of rales over the base of the lung, the area of dulness being char- 
acterized by being convex upward and not changing its area with a 
change in the position of the patient. In those cases where gas is 
present in the abscess cavity there are 3 zones of different resonance 
on percussion. The normal pulmonary resonance above, a zone of 
tympanic resonance caused by the gas, below this, and the area of 
flatness caused by the pus, which is continuous on the right side with 



88 ST. LUKE'S HOSPITAL REPORTS 

the liver flatness. When there is also fluid in the pleural cavity there 
will be 4 percussion zones, an area of flatness intervening between 
the normal pulmonary tympany and the tympanitic zone caused by 
the gas. In right-sided subphrenic abscess the liver is apt to be more 
or less displaced downward. 

It is recommended by all writers on the subject that careful ex- 
ploration with the aspirating needle be made in all questionable cases 
— and the diagnosis from the physical signs being so uncertain, makes 
the majority of cases questionable. The certainty with which the situ- 
ation and size of the abscess is shown in the accompanying radio- 
graphs demonstrates their great value in diagnosis, although probably 
they would not be so plain in a heavy adult as in a child. 

It is believed that had a radiograph been taken in the following 
case, the diagnosis might have been made, as was impossible from the 
physical signs, and the life of the patient perhaps saved. 

M. P., boy, aged 8. Seen in consultation with Dr. J. F. Bell, of Engle- 
wood, N. J., Nov. 7, 1910. Patient had a gangrenous appendix and general 
peritonitis, a large amount of thin pus being present in the general peritoneal 
cavity, as was demonstrated by operation at the Englewood Hospital, three 
hours after being seen by the writer. Patient reacted well from the anaes- 
thetic, and for ten days temperature was between 99° F. and 100° F., and 
bowels moved daily. Patient, however, did not look well, and on the fourth 
day complained of pain in the left chest Examination showed pleuritic 
friction rales over left base, which disappeared two days later, although he 
still complained of pain in left chest and abdomen, which pains continued 
irregularly for several days. On the tenth day after the operation he still 
complained of these pains, as well as pain in the throat and ears, and the 
temperature rose to 104.3° F., pulse 180. Careful, complete examination, as 
well as exploration of the wound, was negative. This examination was veri- 
fied on the following (the twelfth) day by two additional physicians, who 
examined him in consultation. His leucocyte count was 21,400, with 79 per 
cent of polynuclear cells. On Nov. 19th, the morning of the twelfth day, after 
a period of apparent relief and temperature subsidence, he suddenly developed 
at 8 a.m., a harassing cough, with scant mucous expectoration. At 9 a.m. there 
occurred an enormous purulent expectoration, which became bloody as edema 
developed, with cyanosis, evidently the rupture of an abscess into the lung. This 
expectoration showed the presence of streptococci and some diplococci and a 
bacillus, apparently the bacillus coli communis. The respiration became more 
shallow, cyanosis was marked, and the pulse ran up to 204. In about an hour 
and a quarter the patient died, apparently drowned by the pus in the lung. 

An autopsy in this case was refused, and while it is possible that 
the abscess which ruptured might have been in the lung or mediasti- 
num, there were certainly no physical signs indicating its presence 




Fig. 2. — Showing tube in abscess cavity, between liver and diaphragm. 




Fig. 3. — Showing condition on discharge. 



SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS 89 

except the friction rales over the left base for a few days, and no sub- 
jective symptoms except pain in the left chest and shoulder. It is, 
therefore, believed that this was a subphrenic abscess which ruptured 
through the diaphragm into the lung, which, in the absence of physi- 
cal signs, might have been demonstrated by the X-ray in time to save 
the patient. 

Treatment of subphrenic abscess consists of evacuation of the pus, 
either by means of an incision in the loin or abdomen, after dealing 
with the primary cause, and drainage with a rubber tube. This 
method was followed in the first case reported, and was satisfactory 
as long as the drainage tube was kept in place. 

In abscess high up under the diaphragm, more satisfactory drainage 
is obtained by the subpleural route, the tenth rib being resected in the 
mid axillary line and the abscess opened through the diaphragm be- 
low the pleural reflection. 

If the incision opens the pleural cavity (trans-pleural route), the 
pleura above should be closed, and the diaphragm sutured to the in- 
tercostal muscles in the incision, to close off the cavity above before 
opening the abscess, which is then drained with a large rubber tube. 



FIVE CASES OF ESOPHAGEAL OBSTRUCTION FROM 
THREE DIFFERENT CAUSES. 

Nathan W. Green, M.D. 

During the past eight months there have occurred on the ser- 
vice of Dr. Robert Abbe (Surgical Division A) five cases of ob- 
struction of the esophagus from three different causes. The first 
was in a child of 2 years, due to a foreign body which had lodged 
in the lower part, just above the diaphragmatic opening. The next 
two were also in children, one of 3, and the other of Sy 2 years, due 
to the drinking of caustic fluids which had been carelessly left about. 
These were practically impermeable strictures except to small amounts 
of fluid. The last 2 cases were due to cancer, one situated 10y 2 inches 
from the upper alveolar border, and the other at the cardiac extremity 
of the esophagus. 

Brief histories of these cases follow : 

OBSTRUCTION OF THE ESOPHAGUS FROM A STEEL BALL CAUSING A BALL VALVE. 

Surgical No. 85,611.— J. G., 2 years old, was admitted to the service of 
Dr. Robert Abbe (Surgical Division A) May 20, 1911. He was previously 
a normal, healthy baby. For twenty-four hours before admission, he had 
been unable to retain food. Although he appeared hungry, he expelled 
everything a few minutes after eating. There was no blood and no 
fever nor chill. For the three or four hours previous to admission, he had 
refused both solids and liquids. He had not cried, nor did he have severe 
pain or discomfort. 

On examination he appeared restless and anxious. His mouth and tongue 
were clean. Skin and mucous membranes clear. There were no rashes. I lis 
heart and lungs were normal. There was no distention, no tenderness nor 
rigidity of the abdomen. No mass was felt, nor localized tenderness in any 
part of the body. The child vomited everything given him as soon as the 
smallest quantity was taken. There was obstruction to the passage of food. 
The child could not swallow water. In the evening of the day of admission 
(May 20th), he vomited a small quantity of brownish fluid tinged with blood. 
He was taken to the operating room shortly after, and an instrument was 
passed about ten inches, but no metal nor stone object could be felt. 

90 




Fig. 1. — This picture shows steel ball at cardiac end of the esophagus before 

its displacement. 




Fig. 2. — X-ray, showing steel ball displaced into stomach, with coin 
catcher at its side. This picture has been reversed in printing. A. — Picture 
of steel ball, % inch in diameter, which caused esophageal obstruction. 



ESOPHAGEAL OBSTRUCTION 91 

An X-ray was taken on the 21st, showing an object opposite the 8th rib, 
round and looking like a button. Fig. 1. 

On the 22d, he was again taken to the operating room, and the esoph- 
agoscope was passed under ether with the aid of vision. The entire mucosa 
of the esophagus looked healthy, but no definite foreign body could be seen. 
At the end of the tube there was, however, a dark spot, but this was not 
clearly defined. The esophagoscope was withdrawn and a coin-catcher thrust 
into the stomach. An X-ray was taken with this instrument in place, and 
showed that the foreign body had been displaced, and now lay in the stomach, 
below the diaphragm. Fig. 2. 

The night following this treatment the child did not vomit, nor did he 
vomit since that time while in the hospital. 

On May 26th he passed a large semi-formed stool "containing a marble." 
This marble proved to be a steel ball such as is used in ball bearings of 
motor cars. Fig. 2A. This had acted at the cardiac end of the esophagus. 
as a ball for a ball valve, and had absolutely prevented his swallowing. 

On June 1st he was discharged in good condition. 

TWO CASES OF STRICTURE OF THE ESOPHAGUS FOLLOWING THE INGESTION OF A 

CAUSTIC FLUID. 

Surgical No. 86,880.— C. D., 3 years old, was admitted to the service of 
Division A, September 12, 1911, with the history of having swallowed some 
concentrated lye in April, 1910. For a short time after this he was able to 
swallow solid food, but gradually obstruction increased, and everything solid 
would be regurgitated immediately after taking. By feeding with thin 
broths and milk, he had been kept alive. 

On admission he was thin, pale and delicate, with some involvement of 
the right lung. His heart and other viscera were normal, with the excep- 
tion of an obstruction of the esophagus, impermeable except to small amounts 
of fluids. 

Two days after admission, a gastrostomy was performed by Dr. Schley, 
and through this his nourishment was given until his condition sufficiently 
improved to warrant further interference. With the co-operation of Dr. L. T. 
Le Wald, it was possible to obtain good X-ray pictures of his esophageal 
condition. Fig. 3. 

On the 3d of November he was taken to the operating room, and by the 
aid of the esophagoscope a filiform bougie was passed through the stricture 
into the stomach. This was followed by a silk string, and the esophagus 
was then dilated by means of the Abbe string cutting method 1 * * to about 
a 20 French bougie. The next day the patient retained the water given him 
by mouth. 

On the 6th of November he was again X-rayed, and on the 10th still 
another picture was obtained, after which he went to the operating room for 

] G. Gottstein, Keen's Surgery, 1910, vol. iii, p. 808. 
3 R. Abbe, N. Y. Med. Record, 1893, Nr. 25. 
3 R. Abbe, Ann. of Surg., 1893, vol. xii. 



92 ST. LUKE'S HOSPITAL REPORTS 

a second string cutting operation. The esophagoscope was introduced about 
6 inches to the top of the first stricture, a small bougie then introduced 
through the constriction into the stomach, and to it was tied a silk string. 
The operation of the previous week was repeated until a number 34 French 
bougie was passed into the stomach. An attempt was made before passing 
this bougie to pass a bougie & Boule. This engaged its tip at the lower 
stricture, but it could not be forced through even with the aid of the string- 
sawing.* 

On November 17th and 18th, the note is made that an 8-oz. feeding was 
taken by mouth, and he retained his nourishment. A number 28 bougie has 
since been passed twice a week for a number of weeks, and the patient now 
takes the greater part of his nourishment by mouth. 5 

Highest temperature after operation was 102 3-5°, and highest pulse rate 
160°. 

Surgical No. 87,688. — D. B., 3% years old, was referred by Dr. Withington, 
of Pittsfield, Mass., to the service of Dr. Robert Abbe, Division A, and was 
admitted November 26, 1911. 

About 9 months previous to admission, the child swallowed some potash 
used for cleaning. Prom that time there was a constantly increasing diffi- 
culty in swallowing. Finally, everything taken into the mouth was regurgi- 
tated. Upon examination, she was found weak, greatly emaciated and im- 
passive. Heart and lungs normal. By X-ray examination (Dr. Le Wald), 
with the aid of bismuth, a distention of the upper part of the esophagus 
with an almost complete obliteration of the remainder was shown. Fig. 4. 

On November 27th a gastrostomy was performed under ether and a tube 
left in place. Feedings of fluids were begun at once through this tube. 

On December 22d, by aid of the esophagoscope, and impossible without it, 
a Aliform bougie was passed through the stricture as in the previous case. 
This was followed by a silk string, and the string cutting operation was 
performed by Dr. Abbe. This was continued until the esophagus would per- 
mit of the passage of a number 30 French bougie. After a few days, a num- 
ber 28 bougie was passed every week, and latterly twice a week. 

The patient then took and retained almost all of her food by mouth. On 
January 7th she had not had any gastrostomy feeding for 10 days. On the 
31st she weighed 31 lbs. 4 ozs., a gain of 12 pounds. The gastrostomy 
wound was closed, and all food was taken and retained by mouth." 

Highest post-operative temperature, 101°; highest pulse rate, 120°. 

TWO CASES OF MALIGNANT STRICTURE OF THE ESOPHAGUS. 

Surgical No. 87,414.— Mrs. I. A., 54 years old, Russian, and a widow, was 
admitted to the service of Dr. Robert Abbe (Surgical Division A), on 

*It was interesting to note that the distance from the upper teeth to the 
cardiac opening, by palpation with the index finger in the stomach, was 
precisely 10y 2 inches; in this child 37 inches long. 

5 On May 1, 1912, he had gained several pounds, and takes all his nourish- 
ment by mouth, and has a No. 34 F. bougie passed once in 7 to 10 days. 

•She now weighs 37 pounds and 4 ounces, April 15th. 



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ESOPHAGEAL OBSTRUCTION 93 

October 31, 1911. Her chief complaint was inability to swallow. About 
six months ago she first noticed this difficulty, which was limited chiefly 
to solid food. She had grown thin, was hungry, but could not eat. She 
had no pain, with the exception that she had feeling of discomfort when 
a piece of food lodged in her esophagus. Neither her past nor her present 
history had salient points. Her family history was negative. Upon her 
admission she appeared to be a poorly nourished woman, chronically ill. 
Upon attempts to swallow, food regurgitated frequently. Her lungs were 
clear, heart slightly enlarged, her abdomen soft and relaxed, with no 
tenderness nor masses. 

Her liver was two inches below costal margin in middle line. There was 
no tenderness. Examination of her esophagus showed some obstruction. 
A gastrostomy was done on November 3d, by Dr. Abbe, under local anaesthesia, 
and a tube introduced, and by means of this the necessary feedings were 
carried on. 

Examination of the esophagus by bougies showed the presence of a stric- 
ture 8 mm. in diameter and 10y 2 inches from the upper incisor border. 

An X-ray and bismuth picture of the stricture was taken with the as- 
sistance of Dr. Le Wald. The lower end of the esophagus was plugged by 
pulling up through the gastrostomy opening the ball of a bougie a Boule 
upon a stout silk thread. The patient was then directed to swallow 2 ozs. 
of bismuth sub-carbonate suspended in a fermented milk product, and at 
once the X-ray was taken. The result is shown in the accompanying 
picture (Fig. 5). The whole clinical picture was one of malignant disease, 
but it was impossible to confirm this by a pathological section. 

After some dilatation of the stricture with the appropriate bougies and 
the string sawing method, a lead capsule containing 100 mg. of radium was 
introduced by Dr. Abbe and left there for six hours. After this procedure 
the stricture was dilated with a bougie once a week. She was shortly able 
to swallow with comfort. Upon her discharge from the hospital, Decem- 
ber 18th, although it was not possible to hope for a cure, she was much 
improved. She said she could swallow "everything," and certainly there 
was a great amelioration of her symptoms. She has returned once a week 
to the hospital for observation. 

Surgical No. 88,040.— Mrs. L. L., aged 59. a widow, was admitted to the 
service of Dr. Abbe (Surgical Division A), on December 29, 1911. Her chief 
complaint was inability to swallow. About a year previous to admission, 
she began to notice that food other than soft food was vomited at once. 
The beginning was gradual, but the condition grew steadily worse, so that 
on admission all foods were regurgitated. There was discomfort, but no 
accompanying pain. Her past history was good and her family history 
negative. Upon examination her viscera appeared to be normal, with the 
exception of her esophageal and esophago-gastric region. In her esophagus 
a bougie passed but 13% inches and then met with obstruction. (She was 
rather a short woman and this distance proved to be nearly the length of 
her esophagus, as was shown later at operation.) 

An X-ray and bismuth picture of the esophagus and stomach by Dr. Le 



94 ST. LUKE'S HOSPITAL REPORTS 

Wald showed a stricture at the cardiac end of the esophagus (Fig. 6). The 
diagnosis of carcinoma of this region was made. It was confirmed at the 
operation by Dr. Abbe a few days later. A gastrostomy was performed, and 
a more or less annular carcinoma was demonstrated. 




Fig. 5. — This picture shows the dilated portion of the esophagus above 
the stricture (A), which in this case presents the appearance of malignancy. 
Before taking this picture the esophagus was plugged by pulling up through 
the gastrostomy oj ening the ball of a bougie a Boule. The patient was then 
directed to swallow the bismuth mixture, and the X-ray was taken. The 
position has been reversed in printing. The stricture and the lumen of the 
esophagus have been outlined to facilitate interpretation. 




Fig. (J. — This picture shows a malignant stricture (A) at the cardiac 
end of the esophagus. The esophagus is seen dilated above it, and the 
stomach is also seen containing bismuth below it. Contour of the esophagus 
has been outlined to facilitate interpretation. The tumor mass is indicated 
by the dotted line. 



THREE CASES OF ILEO-COLIC INTUSSUSCEPTION WITH 

REDUCTION AND ANCHORAGE BY MEANS OF THE 

APPENDIX— TWO RECOVERIES. 

Nathan W. Green, M.D. 

Since April, 1911, there have occurred on the surgical service of 
Dr. Abbe, Division A, three cases of acute intestinal intussusception. 
All three came to operation. Two of them recovered. Two of these 
cases were sent in early, one had lasted a longer time. The histories 
and method of dealing with the intussusception may serve to promote 
discussion, and may be of interest. 

Surgical No. 85,972.— J. H., 6 months old, was admitted to the service of 
Dr. Robert Abbe, Division A, June 19, 1911. For 21 hours previous to 
admission, his mother noticed he was very cross, and would gag and scream 
with pain. He refused to nurse, and would not take water. At 5 o'clock 
in the morning of the day of admission, his mother noticed a bloody stool. 
Frequently thereafter this was repeated. At 8 o'clock he began to vomit 
light yellow material. The family physician was called, and sent the infant 
directly to the hospital. He arrived at 1 o'clock. 

Upon examination, a typical sausage-shaped tumor was found extending 
across the abdomen. By rectal examination, the tip of the intussusceptum 
could be felt presenting the feel of a "cervix." The child was operated upon 
at 3 o'clock in the afternoon. 

Operation (Dr. Green).— A median incision was made from the umbilicus 
to the pubis. The transverse colon was found distended and bluish, and the 
ileum was seen passing into it. This sausage-shaped "tumor" extended 
down to the rectum. By gentle squeezing and traction, the intussusception 
was entirely reduced. There was no lack of lustre, nor was there any at- 
tempt at adhesion formation. Some means for preventing its recurrence was 
looked for, and the appendix, presenting itself, was drawn through a small 
slit in the iliac region, where it was anchored. Irrigation with salt solu- 
tion was performed through it. The median wound was closed in layers. 
The appendix sloughed off in two days and both wounds healed uneventfully, 
leaving no sinus. 

The patient was discharged cured July 5, 1911, eighteen days after 
operation. 

Surgical No. 86,746.— G. A. W., 8 months old, was admitted to the service 
of Dr. Robert Abbe (Division A), on the 30th of August, 1911. The chief 

95 



96 ST. LUKE'S HOSPITAL REPORTS 

complaint was "a prolapse of the rectum." His illness began 3 months 
previous to admission, when what appeared to be a small piece of rectal 
mucosa protruded from the anal ring. There was no vomiting nor passage 
of blood. The "prolapse," which was at first small, gradually became larger. 
It could be apparently reduced. Later the stools contained mucus and much 
blood, still there was no vomiting nor visible distress. On admission, the 
child vomited once, but did not look ill. 

Physical examination showed no rigidity nor tenderness of the abdomen. 
On the left side, extending from the brim of the pelvis to the left costal 
border, there was a hard sausage-shaped mass which was not tender. This 
was best felt when the "prolapse" was reduced. Protruding from the anus 
there was a large sausage-shaped mass consisting of bowel. The tissue was 
quite red and bled easily on handling. At the end of the mass there were 
two openings, one of which was blind, but admitted a probe for 2 inches, 
the other admitted a catheter indefinitely. This entire mass was easily 
reducible just within the sphincter ani, but came out immediately upon re- 
laxing pressure. 

On rectal examination, a firm ring could be felt as far as the finger 
reached, and the ring was much enlarged. 

The child was operated upon the afternoon of September the 1st. 

Operation (Dr. Green).— Through a median incision, the lower part of the 
ileum, the caecum with appendix and ascending colon were found intus- 
suscepted into the transverse and descending colon to an extent sufficient to 
allow the ileo-csecal valve and the mouth of the appendix to present at the 
tip of the prolapsed tumor 5 inches outside of the anus (see picture). With 
gentle traction and pressure below the intussuscepted gut, it was quite easily 
reduced and found in a good and healthy condition. The appendix was 
identified and carried through a small stab wound made in the abdominal 
wall just above and in front of the anterior superior spine of the ilium. It 
was anchored here and the main wound closed. The child returned to the 
ward in fairly good condition, but at 11 o'clock that evening he suddenly 
became worse, and died ten minutes later. 

Surgical No. 87,792.— M. H., 4 months old, was admitted to the service of 
Dr. Abbe, Division A, on December 6, 1911. In the early morning of 
the day of admission, the mother noticed that the child was restless, and 
refused to nurse. Five hours later it passed a bloody stool. The mother 
then sent for her family physician, who came that afternoon and sent the 
child immediately to the hospital. Upon examination, the patient presented 
the appearance of a fat, healthy baby. A typical sausage-shaped swelling 
existed, extending transversely across the abdomen just below the umbilicus. 
The diagnosis of an acute intussusception was made and at 5 o'clock in the 
afternoon she was operated upon. 

Operation (Dr. Green).— Through a median incision extending from the 
umbilicus to the pubis, the bowel was reduced by careful squeezing with one 
band and traction with the other. The intussusceptum proved to be the 
appendix, caput coli ileum and ascending colon in the order named. The 
Intussuscipiens was the transverse colon. There was no evidence of any 




Fig. 1. — Ileo-colic intussusception, showing protrusion of tumor, with ileo- 
cecal valve at the tip. 




Fig. 2. — Another view ot protruding ileo-colic intussusception in Case. 2. 



ILEOCOLIC INTUSSUSCEPTION 97 

tendency to adhesion formation, nor was any lymph thrown out. Through 
a stab wound in the right iliac fossa the appendix was drawn out, and its 
mesentery and serosa anchored to the peritoneum, the appendix being placed 
between two wipes. The median wound was closed, using one suture for 
the peritoneum and closing the remaining layers with through and through 
silkworm gut. 

The appendix sloughed away on the 5th day. The stump was closed by 
touching it from time to time with silver nitrite, and 4 weeks after operation 
the patient was discharged cured. 

The child was chiefly breast-fed, after the operation, with the addition 
of a little extra feeding at the suggestion of Dr. Charles F. Collins, who 
kindly regulated the post-operative diet for a week. 



MESENTERIC THROMBOSIS WITH RESECTION OF SIX 
FEET OF SMALL INTESTINE— RECOVERY. 

Nathan W. Green, M.D. 

Surgical No. 85978.— W. A. H., American, school teacher, 43 years old, 
was admitted to the service of Surgical Division A, on the 19th of June, 
1911. Her family history recorded the death of three brothers and one 
sister from tuberculosis. Two sisters were living and well. Her previous 
history was good, and she has had two children, the last eleven years ago. 
Both were well. One week previous to her admission, she ate something 
at a restaurant to which she attributed a diarrhoea, with cramps, which 
lasted two days in spite of castor oil (her elder boy, 14 years old, was also 
ill after eating the same). Three days previous to admission she passed, 
without accompanying pain, a black stool. After that she felt well until 
the morning of the day of admission, when at three o'clock she was awak- 
ened by a severe pain one inch to the left of the umbilicus. The pain did 
not change its position but became steadily worse. She then took an enema 
with but slight result, and collapsed. She had nausea, and after medication 
she vomited. The pain was so severe that a hypodermatic injection of mor- 
phine was required. Her physician, Dr. E. J. Richardson, came in the after- 
noon, and at once sent her to the hospital. The appearance was that of in- 
testinal obstruction. On admission, her temperature was 99° F., pulse 106°, 
respiration 28. She appeared severely and acutely ill. Her abdomen was 
somewhat distended, with acute tenderness all over, but most severe near the 
midline. The distension was symmetrical, percussion tympanitic, but no 
mass was felt. She was operated upon 16 hours after her initial pain. 

Operation (Dr. Green). — Resection of 5 feet 9 inches of ileum with end 
to end anastomosis with a Murphy button. A median incision was made, 
and on opening the peritoneal cavity, a litre of blood-stained fluid drained 
off. Lying more or less transversely from the left iliac-fossa to the ileo- 
cecal region was a coil of gut V/2 feet which was of a reddish-black 
color, with 4 feet of a dark red color. There was no lymph exudate observ- 
able. The intestinal border of the mesenteric fan attached to the impaired 
gut was thickened, red and dusky. There was no angulation nor volvulus. 
The affected portion of gut, together with the thickened part of the mesen- 
tery, was cut away about 4 inches each side of the line of demarkation. 
But as there was not satisfactory bleeding from the remaining ends, more 
was removed until sharp arterial bleeding was encountered. The mesentery 
was ligated with an interrupted chain ligature, and the ends of the gut were 



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MESENTERIC THROMBOSIS 99 

united with a Murphy Button reinforced by a Cushing Stitch. The peri- 
toneum was washed with a Blake Tube. Drainage to the site of anasto- 
mosis was instituted and the wound closed with, through and through, silk 
worm gut sutures. 

As deliberation in testing the ends of the remaining gut was used before 
anastomosis, the time of the operation lasted nearly an hour. The first day 
after operation her temperature rose to 100 4-5° F., pulse, 156; respiration, 28. 
Her highest post-operative temperature was 102 2-5 on the 14th day after 
operation, and was due to an accumulation of pus which then escaped 
through the drainage sinus. She had an intercurrent apical bronchitis, of 
rather severe type, and her sinus discharged for some weeks. An X-ray 
taken July 18, 1911, to locate the Murphy button, showed it in the pelvis 
(Fig. 1). It passed a few days later. 

The patient has gained 35 pounds since her discharge from the hospital 
on August 29, 1911, and has been for several months discharging her duties 
as a teacher. She reported, on February 1st, that she was as well as she 
ever was. 1 

The section of intestine (Fig. 2), when freshly removed, measured 5 feet 
9 inches, without traction upon it. Later, when it was received in the Path- 
ological Department, the length was reported as 2y 2 meters. The pathological 
report is as follows : "Specimen consists of 2M> meters of small intestine, 
with mesentery attached. The diameter of the bowel is about normal. The 
greater portion is of a purplish-red color, and the surface has lost its normal 
gloss. Ten centimeters from the anterior end is a definite line of demarka- 
tion, on the proximal side of which the intestine appears normal. Imme- 
diately beyond this point, it assumes a dark-colored appearance, which grad- 
ually becomes less marked. At a point about 50 centimeters from the distal 
end is a less distinct line of demarkation, but even beyond this the intestine 
is much congested. The mesentery contains much fat, and the veins are 
distinctly dilated. 

"Microscopical examination of a section taken from near the root of the 
mesentery shows a large vein occluded by a thrombus, in which are a num- 
ber of fibro blasts indicating beginning organization. There is some hemor- 
rhage into the areolar tissue, but no marked inflammatory reaction. A sec- 
tion of the mesentery, made nearer the intestine, shows a smaller vein with 
a thrombus attached to its wall on one side, which does not, however, com- 
pletely block the vessel, and shows no signs of organization. The tissues 
about the vessel contain many red blood cells and a few leucocytes. In 
other areas, both arteries and veins are free from thrombi. 

"A section of the intestinal wall shows no remains of epithelial lining. 
The villi and muscularis are densely packed with blood cells, which almost 
completely hide the connective tissue framework and the muscle. The nuclei 
of the muscle and connective tissue cells stain very faintly. The small 
blood-vessels beneath the peritoneum are free from thrombi." 



*For the first two or three months after her resection she suffered from a 
diarrhoea, or, rather, a frequency of defecation. This has corrected itself, and 
now she is normal In this respect 



100 ST. LUKE'S HOSPITAL REPORTS 

The striking appearance at operation, the lack of both arterial and 
venous bleeding on sectioning the gut and its mesentery and the find- 
ings in the Pathological Eeport all warrant the diagnosis of Mesen- 
teric Thrombosis. The clinical picture was almost a facsimile of Dr. 
W. S. Schley's case, reported before the New York Surgical Society 
in 1911, and which is on record in the Medical and Surgical Reports 
of St. Luke's Hospital for 1910. 



PAPILLOMA OF THE BLADDER TREATED BY EXCISION- 
RECURRENCE TREATED WITH RADIUM AND THE 
HIGH FREQUENCY CURRENT. 

Henry G. Bugbee, M.D. 

Prior to 1910, tumors of the bladder were treated by one method — 
excision. In the Journal of the American Medical Association for May 
28, 1910, Dr. Edwin Beer, of New York, described a new method of 
treating papillomata of the bladder by the high frequency current. 
At that time he reported 2 cases so treated with excellent result. 

Since then, Keyes, in the American Journal of Surgery, July, 1910 ; 
Buerger and Wolborst, New York Medical Journal, October 27, 1910, 
and McCarthy, have reported cases which have confirmed Beer's ob- 
servations. 

Beer's second report, Annals of Surgery, August, 1911, gives a 
more detailed account of his early cases, and he adds 3 more. He 
comments as follows: ''From all of these observations (references 
above), based on the application of the high frequency treatment as 
used in some 38 papillary growths, it must be evident to the most 
sceptical that in this new method we have raised a mighty rival to 
the older suprapubic and to the transperitoneal and operative cysto- 
scopic methods. I believe it will supplant previous methods, because 
of its greater simplicity and its great effectiveness." 

The case which I wish to report is that of a patient, 56 years of 
age, who has been under the care of Dr. Robert Abbe since 1903, and 
which I have had the pleasure of studying in conjunction with him, 
for the past 2 months. 

The record of the case is as follows: 

There is nothing of note in the patient's history until 1903. He had 
always enjoyed good health, was of large frame, well nourished. Eight years 
ago he began to notice a slight irritation in the bladder and a faint, bloody 
tinge to the urine. Urination became more frequent, was accompanied by 
slight burning, but no pain or actual distress, and the stream had good 
volume and force. An X-ray examination was made with negative result. 

This condition prevailed until July, 1905, when a cystoscopic examination 

101 



102 ST. LUKE'S HOSPITAL REPORTS 

by Dr. Abbe revealed a papilloma of the bladder. The growth was benign, 
villous, pedunculated, the size of a hen's egg, located above and slightly 
posterior to the right ureter in the Bas-fond. This Dr. Abbe removed 
through a suprapubic opening. Not only was the growth removed, but a 
wide excision of the bladder mucous membrane made about the pedicle. 
The convalescence was rapid, the wound closing at once, and the patient 
was well until 1907, when blood again appeared in the urine. Cystoscopy 
revealed a recurrence of the growth at its former site, i.e., above and pos- 
terior to the right ureteral orifice. This recurrence was a tumor of the same 
characteristics as the original growth, but smaller (about the size of a wal- 
nut). An application of a radium tube, bound to a probe, was made to 
the growth through a direct cystoscope, by Dr. Abbe and Dr. F. Tilden 
Brown. The tumor disappeared rapidly and the patient was free from sym- 
toms for 1 year. In 1908 he again had hematuria, but a cystoscopic ex- 
amination by Dr. Abbe showed no growth. The blood disappeared after 
administering gallic acid. 

The following year, a return of the hematuria led him to consult 
Dr. Charles A. Powers, of Denver, near which city he was then re- 
siding, and Dr. Powers reported to Dr. Abbe on the case at that time, 
December 8, 1909, as follows: 

Mr. J. S. B. consulted me December 6th, regarding a recent recurrence of 
bladder hemorrhage. I learn of your operation for the removal of a growth 
in June of 1905, of your application of radium in December, 1907, of the 
slight bleeding through the winter of 1907-08, this controlled by capsules of 
gallic acid. Also of your further examination and good report in December, 
1908. Mr. B. seems to have gone on without definite symptoms until a re- 
turn of hemorrhage during this past month. Of this he will doubtless give 
you a detailed history. He consulted me in order to ascertain, if possible, 
whether it is now best for you to see him in New York. I told him that 1 
could give no opinion without a complete cystoscopic examination, and this 
was made yesterday morning. 

Mr. B. presents no symptoms whatever, excepting hematuria. He has 
no evidence of cystitis, he does not arise at night to urinate, the bladder 
capacity is good. Urination is not painful, there is no residual urine, there 
is only occasional slight staining of the clothing from the meatus. The 
prostate is but very slightly enlarged, its consistency is good, it is not tender. 

A cystoscopic examination was made by Dr. Lyons and myself yester- 
day morning. The bladder wall presents a typically healthy appearance. 
We did not learn the site of your operation, but there seemed to be evidence 
of a scar a little above and to the right of the base of the trigone. Just 
back of the trigone and about in the midline, there is a reddish area less 
than one-half inch in diameter. This area is not ulcerated. It was not 
bleeding at the time of the examination, even when rubbed with the end 
of the cystoscope. 

There was a slight hemorrhage coming from the right side of the pros- 
tatic urethra, little flakes of blood fell from this area, and the membrane 



PAPILLOMA OF THE BLADDER 103 

here was a bit raised. I judge that all portions of the bladder were thor- 
oughly examined; at the end of the 35 minutes the bladder solution was 
not at all discolored. 

Dr. Lyons and I think it probable that the bleeding comes from the pros- 
tatic urethra. Urine was seen coming from the orifice of the left ureter ; 
we could not be certain of this on the right side. The ureters were not 
catheterized. The patient has no kidney symptoms. 

Mr. B. is in excellent general condition; his weight and strength are good; 
he presents no other symptoms than the hematuria. He will send this letter 
to you, and you will advise him. The condition seems to be splendid, in 
view of the removal of a growth in 1905. 

The hematuria was again controlled by gallic acid, and did not 
again appear until June, 1911, when a slight tinging of the urine was 
noticed by the patient. This color became deeper, and he again con- 
sulted Dr. Powers, who cystoscoped the patient, with Dr. Lyons. Their 
report, June 25, 1911, is as follows: 

The bladder held with little or no pain about 12 ounces of fluid; the 
right ureteral opening was found presenting a normal appearance, also the 
superior posterior wall of the bladder and the trigone; the left ureter was 
found a little puffy and edematous, blood was noticed coming from around 
the opening, but on passing a catheter, the urine from the left kidney was 
found to be clear; there was found situated a little above and to the outside 
of the left ureteral opening a smooth, white, heavily stocked growth, the 
size of a hickory nut, a slight congestion and edema of the bladder wall 
surrounded the tumor, but no indurations could be detected. 

From June 25, 1911, to October 17, 1911, the patient passed blood 
very frequently. There was no pain accompanying urination, or at 
other times, but an irritation and sensation of an incomplete emptying 
of the bladder. 

I saw the patient with Dr. Abbe on October 17, 1911. He was then 
in excellent general health. There was slight frequency of urination, 
a good stream, no pain, and but slight irritation about the vesical neck. 
There was a tinge of blood in the last of the urine passed. Eectal 
examination showed enlarged prostate, but the remainder of the phys- 
ical examination was negative. 

A cystoscopic examination was made, with the following results : 

The cystoscope entered the bladder without difficulty or discomfort to the 
patient. The urine evacuated from the bladder was pale and clear. There 
was no blood in it, in contradistinction to that passed by voluntary urination, 
where the last contraction of the bladder, in emptying itself, caused a very 
slight hemorrhage. The bladder was filled and held 10 ounces of fluid with- 
out discomfort. An examination of the mucous membrane of the bladder 
showed a smooth, grayish, glistening surface, throughout the fundus, with 
the exception of 2 areas. The blood vessels were slightly congested. The 



104 ST. LUKE'S HOSPITAL REPORTS 

first of the 2 areas above mentioned was located posteriorly and to the 
outer side of the right ureteral orifice. This area, about 1 cm. in diameter, 
was paler than the surrounding mucous membrane, devoid of blood vessels, 
and resembled scar tissue. This was apparently the site of the original 
growth, and the first recurrence. The second abnormal area was in a sim- 
ilar position on the opposite side of the bladder. Here was found a growth 
about 2 x /o x iy 2 cm. in size. The growth was grayish in color, villous, and 
fairly solid in appearance. On first sight, it appeared to surround the left 
ureteral orifice, but a pedicle was later observed. The mucous membrane 
about the growth was edematous. The urine coming from the ureteral ori- 
fice was clear. The growth could be made to bleed by touching it with the 
cystoscope. 

The prostate gland was moderately enlarged, and the vessels on its sur- 
face congested. The right ureteral orifice was normal in appearance and 
functionated regularly, clear urine being emitted. 

The area of the trigone was negative. 

October 18, 1911.— Through an indirect catheterizing cystoscope the in- 
sulated wire from the high frequency machine was passed into the bladder 
and made to impinge the growth. Four applications of 30 seconds each 
were made to the growth, which became charred and gray and rapidly dis- 
integrated. The operation gave the patient no pain. Following the appli- 
cation the urine was tinged with blood for 3 days, but there was no dis- 
comfort. 

November 3, 1911.— Cystoscopic examination showed the central area of 
the growth destroyed, and a gray spot, 1 cm. by 1 cm., to the outer and 
posterior aspect of the left ureter. Above and below this spot was a small 
nodule of growth, soft, villous, and not bleeding. The mucous membrane 
about the ureteral orifice was edematous. Clear urine came from the open- 
ing. Remainder of the bladder as when first examined. 

November 16, 1911.— There is much less edema of the mucous membrane 
about the site of the growth. A soft, villous, reddish growth the size of a 
pea has appeared high up on the left lateral wall of the bladder since the 
last cystoscopy. The high frequency current was applied to this and to the 
small nodules at the margin of the left ureter, for iy 2 minutes each. 

November 20, 1911.— Cystoscopy showed that the new growth on the lat- 
eral wall, high up, had disappeared. One of the nodules about the left 
ureteral orifice had disappeared, and the second was so small as to be 
scarcely visible. There was less surrounding edema than after the first ap- 
plication of the current. 

November 27, 1911.— Cystoscope passed for the purpose of making one 
more application of the high frequency current, but examination showed 
that the bladder wall was everywhere normal, no vestige of a growth being 
visible. 

December 3, 1911.— Patient states that he has been perfectly comfortable, 
and left for his home in the West. 

This case is reported primarily to show the results of the treat- 
ment of the tumor with the high frequency current. 



PAPILLOMA OF THE BLADDER 105 

Two applications, an aggregate of 3y 2 minutes of contact with the 
current, destroyed the growth, first seen about the left ureteral orifice. 

One application of iy 2 minutes destroyed the small growth on the 
lateral wall. 




Fig. 1. — Cross-section of bladder, showing position of recurrence; also 
small growth in fundus, which appeared between treatments, and was destroyed 
by one application of the high-frequency current. 

The treatment was painless, and followed by no uncomfortable or 
serious consequences. There was no resulting ulceration, and but 
slight bleeding after the application of the current. 

This method of treatment of benign papillomata is simpler than 
any other, and in this case, as in others reported, is quite as effectual. 
There is no reason to believe that the growth will not recur, but 
recurrence is the rule after removal by any method. 



BILATERAL STRICTURE OF THE URETERS. 
Henry G. Bugbee, M.D. 

Mrs. H., 33 years, married. Family and past history to 1897 negative. 
At this time she was operated upon for double pyosalpinx and both tubes 
and ovaries were removed. Following this operation she developed dull pains 
in the lumbar region of the back on either side and severe pain in the pelvic 
region. In 1907 she was operated upon for pelvic adhesions and a second 
operation for the same cause was performed later in the year. There was 
little relief from the lumbar pains. 

In 1908 a third operation for a pelvic tumor. The pain in the lumbar 
region has continued. Urination has been more frequent by day; once or 
twice at night. Slight burning at the end of urination. No blood or cloud 
in urine. 

November 1, 1911. Chief Complaints.— Frequency of urination, pain in 
each lumbar region of the back. 

Physical Examination.— Medium frame. Well nourished. Good color. 
Chest, negative. Abdomen: There is a scar 4 inches long in the lower, 
median line of the abdomen. Also one 2 inches to either side of it. There 
is a slight bulging of the median scar when the patient coughs. Each kidney 
can be palpated, is tender, but not perceptibly enlarged. Liver and Spleen: 
not felt ; no masses or other points of tenderness. 

Vaginal Examination.— Uterus normal size and position. Analysis of 24- 
hour specimen of urine was negative. Cystoscopic examination shows a 
normal bladder. 

The right ureteral orifice was slightly edematous, the left normal. Each 
shows very slight contraction when functionating. No swirl of urine could 
be observed coming from either. 

A catheter entered the orifice on either side, but was arrested 3 cm. from 
the bladder on the left side and 4% cm. from the bladder on the right side. 
Other catheters were substituted, but none would advance beyond these 
points of constriction. A filiform was passed through the constriction and 
on to either kidney. The feeling conveyed by the filiform was that of grip- 
ping rather than encountering an obstruction. The condition was that of a 
stricture of each ureter. 

The catheters placed in either ureter, low down, allowed a separation of 
the urine from the kidneys. The dropping of the urine was not in four or 
five drops, then a pause, but was very slow and regular. The urine was 
clear. 

106 




Fig. 1. — The ureteral catheters show the point of constriction in either 
ureter. The inability to distend fully the pelves and calices of the kidneys is 
also shown. 




Fig. 2. — The ureteral catheter on the right side is seen, having passed 
through the stricture. The left ureteral catheter is not clearly defined, but 
both kidneys are distended. The left kidney, pelvis and calices are dilated. 



BILATERAL STRICTURE OF THE URETERS 107 

Following the examination, the patient had a sharp attack of pain 
in either kidney region, resembling renal colic. This lasted several 
hours, and subsided. 

November 14, 1911.— The cystoscope was again introduced and an attempt 
made to catheterize the ureters, but the same obstruction was encountered. 
Filiforms were passed as before, followed by olivary bougies, sizes 2 and 3 F. 
There was no pain following the stretching, but some relief of the old pain 
in the back with less frequency of urination. 

November 23, 1911.— It was possible to pass a No. 5 F. catheter through 
the constriction of the right ureter and the flow of urine from the catheter 
was rapid. The catheter was obstructed 3 cm. from the bladder on the 
left side. Dilatation was carried out as on the previous occasions. 

December 1, 1911.— Catheters were passed up the right ureter to the pelvic 
brim, and in the left but 3 cm. Argyrol injections of the ureters and kidneys 
were made (40% Argyrol in 2% boric acid). Six c.c. in the right and 4 c.c. in 
the left. There was slight pain in either kidney following the injection. 
The patient stated that this pain was exactly like the pain which she had 
previously suffered. X-ray pictures were taken which show the point of 
stricture in either ureter, that in the left being lower down. There is a 
slight dilatation of the pelvis of the left kidney. 

December 12, 1911.— It is possible to pass a No. 5 F. catheter to either 
kidney. Patient has very little of the old pain and but slight frequency of 
urination. 

December 19, 1911.— Ureters again dilated and catheters passed. No. 5 F. 
catheters to both kidneys. 

December 27, 1911.— Catheters passed beyond stricture of either ureter 
and Argyrol injections made. The Argyrol passed to the kidneys easily, 
allowed a dilatation of the kidney pelvis, and the patient had a slight renal 
colic on either side. 

The X-ray photograph shows the ureters to be open throughout 
their extent and a dilatation of the pelvis of the left kidney. 

The condition is stricture of either ureter, caused by an inflamma- 
tion in the ureteral wall, probably from the same cause as the tubal 
infection. It is analogous to a urethral stricture and may be treated in 
the same manner. A relief of the urinary symptoms and diminution 
of the renal pain have followed the dilatation of the strictures, and 
show the possibilities of conservative treatment. This dilatation can, 
in all probability, be carried up to No. 8 or 10 F., and the stretching 
done less frequently. 

The process of slow dilatation has given the patient no pain or 
inconvenience, and seems to be justified in every case where a stricture 
can be diagnosed. 

Kelly, in the Journal of American Medical Association, August 16, 



108 ST. LUKE'S HOSPITAL REPORTS 

1902, reports several cases treated in this manner. The symptoms in 
his cases were similar to the above. He states that the diagnosis is 
seldom made, and that the majority of cases are treated for hydro- 
nephrosis. Strictures are rarely bilateral, usually found in the pelvic 
ureter, and are caused most frequently by a gonorrheal or tubercular 
inflammation. 

The symptoms are those of vesical and renal inflammation. The 
ureters can often be palpated through the vaginal wall. 

The ureteral orifice, through the cystoscope, appears swollen, may be 
ulcerated, the opening is often obscured, may be a dimple, or indicated 
only by radiating lines. 

Urine usually flows freely after passing a catheter through the 
stricture. 

Kelly has found dilatation the ideal treatment, except in tubercu- 
losis. 

Other methods of treatment are ureteral catheterization and irri- 
gation, freeing of adhesions, resection of the ureter, extirpation of the 
tract, and transplantation. 



Medical Service 



MEDICAL STATISTICS FOE 1911 



DISEASES DUE TO MICRO-ORGANISMS 



INFECTIVE DISEASES 



Sex 




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Cerebrospinal fever 

Diphtheria 

Dysentery (amoebic) 

Dysentery (amoebic), bronchitis, polycythemia. 

Enteric fever, intestinal hemorrhage 

Erysipelas 

Filiariasis, chyluria 

Gonococcus arthritis of elbow 

Gonococcus arthritis of knee 

Gonococcus arthritis, pregnancy 

Gonococcus arthritis, urethritis 

Influenza 

Influenza, otitis externa 

Malaria 

Malaria (tertian) 

Rheumatism (subac. artic. ) 

Rheumatism (subac. artic), cardiac arrhythmia 
Rheumatism (subac. artic), mitral insufficiency 
Rheumatism (subac. artic), retroversion of 

uterus, nephritis, cardiac hypertrophy 

Rheumatism (subac artic), strongyloides intes- 

tinalis 

Rheumatism (ac. art.) 

Rheumatism (ac. art.), bronchitis, emphysema, 

nephritis, uremia 

Rheumatism (ac art.), carcinoma of gall bladder 

Rheumatism (ac art.), herpes zoster 

Rheumatism (ac art.), lymphangitis 

Rheumatism (ac art.), mitral and aortic insuffi 

ciency 

Rheumatism (ac. art.), mitral insufficiency 

Rheumatism (ac art.), mitral stenosis, fibrinous 

pericarditis 

Rheumatism (ac. art.), nephritis 

Rheumatism (ac art.), pericarditis 

Rheumatism (ac art.), pericarditis (fibrinous), 

lobar pneumonia 

Rheumatism (ac. art.), regurgitation (mitral), 

pericarditis (fibrinous) 

Syphilis (secondary) 

Syphilis (secondary), multiple alcoholic neuritis 

Syphilis (tertiary) 

Syphilis (tertiary), aortic aneurysm 

Syphilis (tertiary), aortic insuff., aortitis.... 
Syphilis (tertiary), aortitis, mitral and aortic 

insufi*., cardiac decompensation 

Syphilis (tertiary), aortitis, tabes dorsalis, chr 

nephritis, cirrhosis of liver 

Syphilis (tertiary), cerebral endarteritis, throm 

bosis 

Syphilis (tertiary), gumma of post-pharyngeal 

walls, keratitis 

Syphilis (tertiary), gumma of spinal cord 

Syphilis (tertiary), hepatitis 

Ill 



24 



112 



ST. LUKE'S HOSPITAL REPORTS 



DISEASES DUE TO MICRO-ORGANISMS— 
Continued 



Infective Diseases — Cont. 

Syphilis (tertiary), hepatitis, aneurysm of arch 
of aorta 

Syphilis (tertiary), periosteitis of cranium 

Syphilis (tertiary), periosteitis of femur 

Syphilis (cerebral) 

Syphilis (cerebral), hemorrhage into cerebrum.. 

Syphilis (cerebral), lobar pneumonia 

Tuberculosis of axillary glands, tbc. fibrosis of 
lungs and pleurae 

Tbc. of chest wall 

Tbc. of kidney 

Tbc. of kidney and bladder 

Tbc. of knee joint 

Tbc. of lungs 

Tbc. of lungs, arterio-sclerosis, chr. nephritis. . . . 

Tbc. of lungs, bronchitis 

Tbc. of lungs, diabetes mellitus, hydropneumo 
thorax, gangrene of lung 

Tbc. of lung, gastritis, cirrhosis of liver 

Tbc. of lungs, lobar pneumonia 

Tbc. of lungs, ischio-rectal abscess 

Tbc. of lungs, nephritis 

Tbc. of lungs, pernicious anemia, arterio-sclerosis 

Tbc. of lungs, pleurisy with effusion 

Tbc. of lungs, pneumothorax 

Tbc. of lungs, tbc. enteritis 

Tbc. of lungs, tbc. fistula in ano 

Tbc. of lungs, tbc. of larynx 

Tbc. of lungs, tbc. of larynx, aortic regurgitation 

Tbc. of lungs, tbc. meningitis 

Tbc. of lungs, tbc. of spine, bronchitis, fibrinous 
pleurisy 

Tbc. of lungs, tbc. of spine, tachycardia 

Tbc. of hip 

Tbc. of peritoneum 

Tbc. of pleura 

Tbc. of spine 

Tbc. of spine, tbc. of lungs, tachycardia 

Tbc. meningitis 

Tbc. meningitis, chr. nephritis 

Tuberculosis (miliary), tbc. peritonitis, nephritis 

Typhoid fever 

Typhoid fever with hemorrhages 

Typhoid fever with relapse 

Typhoid fever, bronchitis 

Typhoid fever, broncho-pneumonia 

Typhoid fever, ischio-rectal abscess 

Typhoid fever, laryngitis (ac.) 

Typhoid fever, mitral and aortic insuff 

Typhoid fever, otitis media 

Typhoid fever, periosteitis 

Typhoid fever, phlebitis 

Typhoid fever, pulmonary embolism 

Typhoid fever, pneumothorax, cholecystitis 

Typhoid fever, pyelitis 

Typhoid fever, peritonitis, ac. catarrhal cholecys- 
titis 

Typhoid fever (para-typhoid) 

Typhoid meningitis 



ALIMENTARY SYSTEM 



INTESTINES 



Colitis 

Colitis (ulcerative) 

Colitis (ulcerative), bronchitis 

Colitis (ulcerative), ethmoiditis 

Constipation, arterio-sclerosis 

Constipation, mitral stenosis and insuff., aortic 
insuff 



166 



189 



171 



1 
2 
1 

34 

"2 



128 



23 



18 

1 



53 



MEDICAL STATISTICS— 1911 



113 



ALIMENTARY SYSTEM— Continued 


<5 


a 
fa 


U 


a 

a 


a 


5 


o 
H 


Intestines — Cont. 


1 

1 


' 2 

1 
1 

1 
1 


1 
1 
1 

2 








1 




2 






3 


Entero-colitis 


1 


Enteroptosis, hyperchlorhydria, pyloric stenosis. 
Enteroptosis, retroversion of uterus, constipa- 
tion (chr. ) 




1 

1 
1 


1 

1 


i 

3 
3 


1 
1 


Gastro-enteritis 


2 

1 
1 

1 


3 


Ileus 


1 


Ileus, aortic and mitral insuff., aortic stenosis. . . 


1 
1 




1 






i 

6 

2 
1 


1 








LIVER 


8 
1 


16 

1 
1 
5 
4 

1 
1 

" i 
1 

' i 
l 
l 


8 
. . ._. 


7 

. . ... 

6 
3 

1 

1 

1 
2 

1 
1 
1 

1 

' i 
l 

l 


24 

2 




1 


Cirrhosis of liver 


5 

1 
1 


10 


Cirrhosis of liver, alcoholic peripheral neuritis , 
Cirrhosis of liver, alcoholic psychosis 


4 
1 


Cirrhosis of liver, arthritis (ac), ascites, myo- 
carditis 


1 


Cirrhosis of liver, ascites, cardiac dilatation, ne- 


1 


Cirrhosis of liver, catarrhal gastritis 


1 
1 

1 


2 


Cirrhosis of liver, hematemesis 

Cirrhosis of liver, hemorrhoids, mitral insuff 
Cirrhosis of liver, fistula in abdominal wall... 


1 
1 
1 


Cirrhosis of liver, intestinal hemorrhages, alco- 
holic delirium 






1 


Cirrhosis of liver, Korsikoff's psychosis 


1 




1 


Cirrhosis of liver, mitral regurgitation 




1 










1 


Cirrhosis of liver (hepatic), secondary anemia. 


1 


1 


BILE PASSAGES 

Catarrhal jaundice 


12 


18 
1 

' '4 

i 
i 
i 
i 

9 
1 

' i 

2 


1 

1 
1 


22 


4 


3 


30 
1 




1 
1 








1 


Cholelithiasis, biliary colic 


5 
1 
2 

1 






5 

1 


Cholelithiasis, cholecystitis 


2 


1 


1 
1 


3 


Cholelithiasis, goiter, hypochlorhydria 


1 


Stenosis of bile duct (congenital), icterus 




1 








9 






MOUTH, TBBTH AND GUMS 


4 


2 

1 
. . ._. 

2 


1 


13 

1 

1 
1 
1 




1 

1 


1 
1 






Stomatitis (mercurial), ac. nephritis 


















OESOPHAGUS 


2 
1 


2 

1 
1 

1 


4 
1 










PANCREAS 


1 
1 


1 
1 




1 
1 






I 




1 

1 




1 


PERITONEUM, ETC. 


1 

i 

2| 




1 
1 
1 






Subphrenic abscess 


1 






1 


2 




l| 


3 



114 



ST. LUKE'S HOSPITAL REPORTS 



ALIMENTARY SYSTEM— Continued 



PHARYNX, TONSILS AND NASOPHARYNX 



Abscess (peritonsillar.) 

Pharyngitis 

Quinzy 

Tonsillitis 

Tonsillitis, pharyngitis 

Tonsillitis (follicular) 

Tonsillitis (follicular), stomatitis 

Tonsils (bypertrophied), phimosis, sciatica. 



RECTUM 

Fecal fistula, mitral and aortic insufficiency.... 
Hemorrhoids, epididymo-orchitis, empyema of tu- 
nica vaginalis 

Hemorrhoids (internal) 



STOMACH 



Anacidity, fracture of rib 

Atony, hyperchlorhydria, senile dementia 

Dilatation 

Dyspepsia 

Dyspepsia (nervous) 

Dyspepsia (nervous), anacidity 

Gastritis (alcoholic 

Gastritis (alcoholic), catarrhal jaundice, mitral 

and aortic insufficiency 

Gastritis (alcoholic), multiple neuritis, tbc. of face 

Gastritis (acute.) 

Gastritis (acute), mitral stenosis 

Gastritis (chronic) 

Gastritis (chronic), hyperacidity 

Gastritis (chronic), neurasthenia 

Gastroptosis 

Hyperchlorhydria 

Hyperchlorhydria, gastritis 

Hyperchlorhydria, gastroptosis 

Hypochlorhydria 

Hypochlorhydria, insomnia 

Hypochlorhydria, senile atrophy of stomach 

Stenosis of pylorus of stomach 

Stenosis of pylorus of stomach, gastric dilatation, 

cardio-spasm 

Ulcer of stomach 

Ulcer of stomach, cystic kidney 

Ulcer of stomach, pyloric stenosis 



VERMIFORM APPENDIX 



Appendicitis (chronic) 

Appendicitis (chr. ), catarrhal gastritis. 

Appendicitis (acute) with abscess 

Appendicitis (acute) with peritonitis... 
Appendicular colic 



CARDIO-VASCULAR SYSTEM 

BLOOD 



Anemia (pernicious.) 

Anemia (secondary) 

Anemia (secondary), nervous exhaustion.. 

Anemia ( simple) 

Anemia (splenic) 

Chlorosis 

Chlorosis, influenza, otitis media 

Chlorosis, mitral stenosis and insufficiency. 
Leukemia (lymphatic) 



17 



38 



6 
2 

' 9 

1 
17 

1 



36 



22 



35 



6 

2 
1 
9 
1 
17 
1 
1 

38 



1 

1 
1 
7 
2 
1 
3 

1 
1 
6 
1 
10 
1 
1 
2 
2 
2 
1 
1 
1 
1 
2 

1 
9 
1 

1 

61 



MEDICAL STATISTICS— 1911 



115 



CARDIOVASCULAR SYSTEM— Continued 



Blood— Cont. 



Leukemia (myelogenous) 

Leukemia (lymphatic), herpes zoster, broncho- 
pneumonia, mitral insufficiency 

Pseudoleukemia, suppuration of axillary glands. 



ARTERIES 



Aneurysm of aorta 

Aneurysm of aorta, aortitis, aortic insufficiency, 
arterio-sclerosis, ac. art. rheumatism 

Aneurysm of aorta, cholelithiasis, nephritis 

Aneurysm of aorta (ruptured), arterio-sclerosis 
nephritis 

Aneurysm of aorta (ruptured), broncho-pneumo- 
nia, emphysema 

Aneurysm of iliac and femoral arteries 

Aneurysm of innominate artery 

Arterio-sclerosis 

Aneurysm of aorta (ruptured), hemothorax, sero- 
fibrinous pleurisy, lobar pneumonia 

Arterio-sclerosis, bronchitis (acute) 

Arterio-sclerosis, constipation (chr. ) 

Arterio-sclerosis, emphysema, myocarditis 

Arterio-sclerosis, emphysema, senility 

Thrombosis of cervical arteries, paralysis of 
pharynx 

Ventricular hemorrhage 

Embolism (cerebral), rheumatic endocarditis. . . . 

Embolism (coronary), mitral and aortic insuff. 
mitral stenosis 



18 



Thrombosis of innominate vein, pyelitis 

Thrombosis of popliteal vein, varicose veins of 
legs 



Angina pectoris ( ?), mitral and aortic insuff. . . . 

Dilatation, cardiac hypertrophy, mitral and 
aortic insuff., mitral stenosis 

Dilatation, mitral stenosis, aortic insuff 

Endocarditis (chr.) 

Dilatation (acute), hydrothorax, pneumonia.... 

Endocarditis (septic) 

Endocarditis (septic), cerebral embolism 

Endocarditis (septic), emphysema, mitral steno- 
sis and insuff 

Endocarditis (septic), mitral stenosis, aortic in- 
suff., sero-fib. pleurisy 

Endocarditis (septic), mitral and aortic insuff.. 

Endocarditis (rheumatic), aortic regurgitation.. 

Endocarditis (rheumatic), pregnancy 

Endocarditis (rheumatic), terminal pneumonia. . 

Fatty heart, sclerosis of coronary arteries 

Myocardial degeneration, arterio-sclerosis, chronic 
nephritis 

Myocardial degeneration, fatty degeneration of 
liver 

Myocarditis 

Myocarditis, aortic stenosis 

Myocarditis, arterio-sclerosis, emphysema 

Myocarditis, arterio-sclerosis, hydrothorax 

Myocarditis, decompensation 

Myocarditis, endocarditis, angina pectoris 

Myocarditis, nephritis 

Myocarditis, osteo-arthritis of hip 

Myocarditis, polycythemia, cardiac insuff 



13 



12 



11 



12 



116 



ST. LUKE'S HOSPITAL REPORTS 



CARDIOVASCULAR SYSTEM— Continued 



Heart — Cont. 



Valvular Diseases : 



Mitral insufficiency 

Mitral insuff., artic. rheumatism 

Mitral insuff., bydrothorax, nephritis 

Mitral insuff., oedema of luDgs 

Mitral insuff. and stenosis 

Mitral insuff. and stenosis, aortic insuff. . . . 

Mitral insuff. and sten. arterio-sclerosis, ehr. 
nephritis 

Mitral insuff. and sten., aortic stenosis 

Mitral insuff. and sten., decompensation 

Mitral insuff. and sten., pleurisy 

Mitral and aortic insufficiency 

Mitral and aortic insuff., fibrinous pleurisy, 
inguinal hernia 

Mitral and aortic insuff., rheumatic endocar- 
ditis 

Mitral and aortic insuff. and stenosis 

Mitral and tricuspid insuff., mitral stenosis. 

Mitral stenosis 

Mitral stenosis and aortic insuff 

Mitral stenosis, decompensation, anasarca. . . 

Aortic insufficiency, aortitis, hemorrhoids. . . . 

Aortic insuff., aortitis, angina pectoris 

Aortic insuff. and stenosis, decompensation. . 

Aortic stenosis 



LYMPH GLANDS 



Ac. lymphangitis, lymphadenitis, tenosynovitis. 
Supp. lymphadenitis of axilla 



DUCTLESS GLANDS 

Goitre (simple), hyperthyroidism, mitral stenosis 
and regurgitation 

Goitre (exophthalmic) 

Goitre (exophthalmic), cardiac hypertrophy and 
dilatation, pneumothorax 

Elephantiasis, abscess of leg 

Hodgkin's disease 

Toxemic hyperthyroidism 



MUSCULAR SYSTEM 



Chr. muscular rheumatism. . . . 

Myalgia 

Progressive muscular atrophy. 



NERVOUS SYSTEM 

BRAIN 



Abscess, eupp. meningitis, polycythemia 

Apoplexy 

Abscess of brain, otitis media, mitral stenosis. 

Apoplexy, cerebral thrombosis 

Apoplexy, hemiplegia. 

Meningitis, bulbar paralysis, pulmonary tbc. . . . 

Meningitis (pneumococcus) 

Paralysis (facial), hyp. tonsils , 

Paralysis (post-diphtheritic) 



DISEASES OF THE MIND 

Mania (acute), bronchitis, emphysema, mitral 
insuff 



49 



1 
' i 

66 

i 
l 



34 



MEDICAL STATISTICS— 1911 



117 



NERVOUS SYSTEM— Continued 


1> 


a 

fa 


d 


a 




5 


O 

Eh 


Diseases of the Mind — Cont. 




1 
1 




1 


1 
1 

3 





I 
1 
1 






Paresis (general) 


1 


NERVES 

Neuralgia of cranial nerve 


1 


3 

2 
' ' 3 

' ' '2 
2 
3 

1 

4 


' ' '2 

1 
1 
1 
1 
2 

' '5 


1 
2 


4 
2 


Neuralgia of intercostal nerve 


2 
4 

1 
1 


2 




7 






7 
1 


Neuritis (alcoholic multiple), Korsikoff's syn- 
drome, pulmonary the 










1 




1 

' i 

1 


1 
1 




2 
2 








1 


4 
1 






1 

10 

3 






5 




12 

2 
1 
3 

8 
2 
13 
1 
1 


2 




NERVOUS DISEASES OF UNKNOWN ORIGIN 


17 

2 
1 
3 
9 
2 
15 
1 


13 
3 

' i 

1 




27 
5 








1 






4 




3 

9 

3 

17 

1 
1 








1 
2 




Neurasthenia, retroversion of uterus 




1 








SPINAL CORD 


7 


33 

1 
1 

2 

"2 

1 

1 


5 


31 

1 

2 
1 

1 


4 

1 
1 

2 


' i 


40 

1 
1 
4 
1 
1 




1 
3 

1 
1 








OSSEOUS SYSTEM 

BONES 


6 

1 




5 

1 
2 
1 
1 


1 


8 

I 
2 
1 

1 


Leontiasis ossia, Paget's disease, mitral insuff . . . 








1 










4 
5 

' 'i 




5 

5 
1 
1 


5 


JOINTS 






5 

1 
1 




1 








1 


6 
2 




7 

1 






7 


REPRODUCTIVE SYSTEM 

OVARIES AND TUBES 


1 




2 






PREGNANCY 




2 

1 
3 


' ' 3 


1 
1 


1 




2 

1 
3 










1 








.... 


4 


3 




.... 


4 



118 



ST. LUKE'S HOSPITAL REPORTS 



REPRODUCTIVE SYSTEM — Continued 



a p 



UTERUS AND FALLOPIAN TUBES 



Dysmenorrhea 

Endometritis, ac. bronchitis 

Menorrhagia 

Pyosalpinx 

Pyosalpinx, appendicitis 

Pyosalpinx, fibroma uteri, broncho-pneumonia, 

fibrinous pleurisy 

Retention of placenta, septic uterus 



RESPIRATORY SYSTEM 



BRONCHI 



Asthma, bronchitis 

Asthma, emphysema 

Asthma, erysipelas 

Asthma, nephritis (chr.) 

Bronchiectasis 

Bronchitis 

Bronchitis (ac), cardiac incompetency 

Bronchitis (ac), dextracardia 

Bronchitis (ac), emphysema 

Bronchitis (ac), mitral insufficiency 

Bronchitis (ac), mitral regurgitation, purpura 

rheumatica 

Bronchitis (ac), myelogenous leukemia 

Bronchitis (ac), strongyloides intestinalis 

Coryza 



Laryngitis 

Laryngitis (catarrhal), fibromyomata uteri, neu- 
rasthenia 



Abscess of lung and gangrene, following lobar 
pneumonia 

Emphysema (pulmonary), bronchitis 

Emphysema (pul.), bronchitis, asthma, paroxys- 
mal tachycardia 

Emphysema (pul.), bronchitis, mitral insuff . . . . 

Pneumonia (broncho-) 

Pneumonia (broncho-), arterio-sclerosis, chr. ne- 
phritis 

Pneumonia (broncho-), varicose ulcer 

Pneumonia (lobar) 

Pneumonia lobar), arterio-sclerosis, chr. nephri- 
tis 

Pneumonia (lobar), alcoholic delirium 

Pneumonia (lobar), articular rheumatism, mitral 
insuff., fibrinous pericarditis 

Pneumonia lobar), atresia of lung 

Pneumonia (lobar), bronchitis, emphysema 

Pneumonia (lobar), fibrinous pleurisy, child- 
birth, dilatation of stomach 

Pneumonia (lobar), fibrinous pericarditis, infarct 
of lung, mitral insufficiency 

Pneumonia (lobar), mitral insufficiency 

Pneumonia (lobar), mitral insufficiency, infarct 
of lung 

Pneumonia (lobar), oedema of lungs 

Pneumonia (lobar), cedema of lungs, myocarditis, 
'chr. nephritis 

Pneumonia (lobar), morphinism 

Pneumonia (lobar), nephritis, hydrothorax. . . 

Pneumonia (lobar), pleurisy (dry) 

Pneumonia (lobar), pleurisy (suppurative)... 



14 



10 



12 

"i 



19 



1 

29 



17 



1 

1 

15 



MEDICAL STATISTICS— 1911 



119 



RESPIRATORY SYSTEM— Continued 



Lungs — Cont. 

Pneumonia (lobar), pleurisy with effusion 

Pneumonia (lobar), streptococcic bacteremia.. . . 
Pneumonia (lobar, resolution delayed), fibrinous 

pleurisy 

Pneumonia (lobar, unresolved) 

Pneumonia (terminal), chr. nephritis 



Pleurisy (dry) 

Pleurisy (dry), pneumonia 

Pleurisy (fibrinous) 

Pleurisy (fibrinous), tachycardia 

Pleurisy (sero-fibrinous), retroversion, endome- 
tritis 

Pleurisy (suppurative) 

Pleurisy with effusion 

Pleurisy with effusion, asthma, bronchitis 

Pyopneumothorax 



SENSE ORGANS 



ORGAN OF HEARING 



Mastoiditis 

Mastoiditis, influenza, otitis media. 
Otitis media (suppurative) 



ORGAN OF VISION 



Atrophy of optic nerve. 

Cataract, diabetes 

Choroido-retinitis 

Keratitis 

Strabismus 



TEGUMENTARY SYSTEM 

SKIN, ETC. 

Erythema multiforme 



URINARY SYSTEM 



KIDNEY 



Albuminaria 

Nephritis (acute) 

Nephritis (chronic interstitial) 

Nephritis ( chr. in. ) , anemia 

Nephritis (chr. in.), appendicitis 

Nephritis (chr. in.), arterio-sclerosis 

Nephritis (chr. in.), arthritis deformans 

Nephritis (chr. in.), anemia, stomatitis 

Nephritis (chr. in.), aortic insufficiency 

Nephritis (chr. in.), cirrhosis of liver 

Nephritis (chr. in.), cirrhosis of liver, cerebral 
hemorrhage 

Nephritis (chr. in.), cirrhosis of liver, parotitis, 
pericarditis, fib. pleurisy 

Nephritis (chr. in.), cystitis, dilatation, myocar- 
dial insufficiency 

Nephritis (chr. in.), colitis, aortitis, rheumatoid 
arthritis, diphtheria 

Nephritis (chr. in.), dry pleurisy, cirrhosis of 
liver 



47 



23 



50 



17 



52 



1 

15 

1 



22 



1 
19 



13 



13 



1 
31 



10 



3 

1 

2 

1 
1 

97 



1 

5 

21 

1 
1 

40 



1 
1 
29 
2 
1 
4 
1 
1 
2 
S 

1 

1 
1 
1 
1 



120 



ST. LUKE'S HOSPITAL REPORTS 



URINARY SYSTEM— Continued 



Kidney — Cont. 

Nephritis (chr. in.), emphysema, cardiac insuf- 
ficiency 

Nephritis (chr. in.), hydrothorax 

Nephritis (chr. in.), mitral stenosis and insuffi- 
ciency 

Nephritis (chr. in.), myocarditis 

Nephritis (chr. in.), peritonitis 

Nephritis (chr. in.), oedema of lungs, lobar 
pneumonia, myocarditis 

Nephritis (acute), parotitis, status lymphaticus 

Nephritis (chr. in.), pleurisy with effusion, car- 
diac insufficiency 

Nephritis (chr. in.), pulmonary hemorrhages, en- 
tero-colitis, uremia 

Nephritis (chr. in.), pulmonary tbc, cirrhosis 
of liver 

Nephritis (chr. in.), mitral regurgitation, hemi- 
plegia, motor hysteria 

Nephritis (chr. in.), uremia 

Nephritis (chr. in.), uremia, fib. pericarditis. . . 

Nephritis (chr. in.), uremia, mitral and aortic 
insuff 

Nephritis (chr. in. with acute exacerbation) . . . 

Nephritis (chr. parenchymatous) 

Nephritis (sub-acute), facial paralysis 

Nephritis (sub-acute), hemianopsia papillitis... 

Nephritis sub-acute) hemorrhage into pons. . . . 

Hydronephrosis 

Nephrolithiasis 

Pyelonephritis 

Pyelitis 

Pyonephrosis, broncho-pneumonia 

Uremia 

Uremia apoplexy 



Enlarged spleen, polycythemia. 



UBINABY BLADDER 



Cystitis, nephritis, cardiac decompensation. 
Cystitis, urethral stricture, catheter fever. . 



DISEASES DUE TO ANIMAL PARASITES 



Tapeworm . 
Unciniarisis 



GENERAL INJURIES 



Heat prostration 

Smoke inhalation 

Starvation, psychosis, chr. colitis. 



LOCAL INJURIES 



Concussion 

Incised wound of hand. 



NEOPLASMS 



Carcinomatosis 

Carcinoma of breast, mediastinal metastases. 
Carcinoma of breast, mitral regurgitation, sub- 
acute rheumatism 



54 



27 



37 



1J 



34 



1 

1 

10 
2 

1 

1 
1 



1 

1 

1 

11 

2 

1 
1 
1 
1 
1 
2 
1 
1 
2 
8 
1 
3 
1 

109 



MEDICAL STATISTICS— 1011 



121 



NEOPLASMS— Continued 



a 

H P 



Neoplasms — Cont. 



Carcinoma of colon 

Carcinoma of liver and bile duct 

Carcinoma of oesophagus 

Carcinoma of pancreas 

Carcinoma of stomach 

Carcinoma of stomach and rectum, chr. nephritis 

Carcinoma of stomach, metastases in liver 

Carcinoma of stomach, omental metastases, tabes 
dorsalis, arterio-sclerosis 

Carcinoma of uterus, anasarca, secondary ane- 
mia, cardiac insufficiency 

Cyst-adenoma (papillary), metastases in lung. . 

Epithelioma of oesophagus 

Epithelioma of pleura, hydrothorax 

Epithelioma of scalp, chr. nephritis, arterio- 
sclerosis 

Exostoses on humerus 

Fibromyoma of uterus, anemia 

Infected arm 

Infected finger 

Sarcoma (retroperitoneal) 

Sarcomata in lumbar region 

Tumor of brain 

Tumor of brain, pulmonary tuberculosis 

Tumor of mediastinum 

Tumor of abdomen 

Tumor of spinal cord 



INTOXICATIONS AND POISONS 



EXOGENOUS INTOXICATIONS 



Alcoholism, acute 

Alcoholism (chr.) delirium tremens 

Alcoholism (chr.), Korsikoff's psychosis 

Chronic poisoning by lead 

Chronic poisoning by mercury 

Chronic poisoning by morphine 

Chronic poisoning by morphine, aneurysm of iliac 

and femoral arteries 

Chronic poisoning by veronal 

Chronic poisoning by strychnine 

Acute poisoning by Paris green 

Pneumococcus septicemia, pulmonary tbc 

Septicemia following abortion, mitral insuff . . . . 
Streptococcic septicemia, imitative meningitis. . . 
Streptococcic septicemia, septic endocarditis. . . . 



ENDOGENOUS INTOXICATIONS 



Auto-intoxication 

Auto-intoxication, cardiac arrhythmia. 

Diabetes mellitus 

Diabetes mellitus, chr. nephritis 

Diabetes mellitus, pulmonary tbc 

Diabetes mellitus, eczema 

Diabetes mellitus, lobar pneumonia. . . . 
Gout 



MISCELLANEOUS CONDITIONS 



Debility 

Heat stroke, meningitis. 

Malingering 

No diagnosis made 



14 



18 



14 



2 



16 



13 



122 



ST. LUKE'S HOSPITAL REPORTS 



SUMMARY 



Micro-organic Diseases. . 

Alimentary System 

Cardio-vascular System . 

Ductless Glands 

Muscular System 

Nervous System 

Osseous System 

Reproductive System . . . 

Respiratory System 

Sense Organs 

Tegumentary System. . . . 

Urinary System 

Animal Parasites 

General Injuries 

Local Injuries 

Neoplasms 

Intoxications 

Miscellaneous 



166 

76 

80 

3 

3 

29 

2 



189 

102 

73 

8 

7 

64 

10 

16 

95 

7 

1 

56 

2 

2 

1 

23 

18 



171 

71 

6 

1 

3 

20 

"i 

95 
2 
1 

27 
3 
3 
2 
2 

12 
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REPORT OF CASES OF HODGKIN'S DISEASE. 
Austin "W. Hollis, M.D., Otto H. Leber, M.D., and F. C. Wood, M.D-. 

Case 1. — The patient, a civil engineer, aged 31 years, came to the 
hospital September 5, 1910, with a general history of fever, and 
progressive loss of flesh and strength extending over a period of a 
whole year. In September, 1909, he had been taken sick with fever 
and general prostration, but stayed in bed for a few days only, and 
then was able to get up and go about his work until January 1. Dur- 
ing all this time, however, he felt badly, and having acquired the 
habit of taking his temperature himself, frequently found that he had 
fever. He then spent 3 months at home, taking moderate exercise, 
but doing no work. At this time he was thought to have incipient 
tuberculosis, and in April went to a boarding-house in Sullivan 
County, and then, 4 weeks before admission, to the Loomis Sanator- 
ium. He thought he had fever three-fourths of the time during the 
past year, but during the month of June there was a complete re- 
mission. 

At the Loomis Sanatorium his temperature ranged from 100.8° to 
105°. According to the patient, he had a moderate cough at the 
times he had fever, and occasionally expectorated a small quantity of 
whitish or yellowish sputum, which once contained a clot of blood. 
He thought he lost about 20 pounds in weight. He had a number 
of heavy night sweats in the spring, and had them almost nightly 
when admitted to the hospital. His appetite was poor when he had 
fever; he had no epigastric pain or symptoms of indigestion; the 
bowels had moved regularly with slight catharsis, and he was never 
troubled with pain anywhere. 

His past history was negative, except for the diseases of childhood. 
His work in engineering has been in this part of the country, mostly 
in wet, swampy districts. He took a glass of beer occasionally, and 
smoked to excess before the onset of his illness. 

There was no family history of tuberculosis. His mother died of 
carcinoma of the stomach ; his father is alive and well. 

123 



124 



ST. LUKE'S HOSPITAL REPORTS 



On admission to the hospital, the patient was moderately pros- 
trated, and markedly emaciated, the latter being accentuated by the 
patient's height of 6 feet 6 inches. The eyes, mouth and throat ap- 

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peared normal; the chest showed very markedly the great degree of 
emaciation ; expansion was good, and equal on both sides. The heart 
appeared normal in size, at the apex and over the pulmonic area there 



HODGKIN'S DISEASE 125 

was a soft systolic murmur. The action was regular, rapid and forci- 
ble. The lungs showed moderate dulness at both apices. At the 
right apex, and just below the spine of the scapula were a few sub- 
crepitant rales. The abdomen was scaphoid; the liver appeared nor- 
mal in size; the spleen descended about 2 fingers below the free bor- 
der on inspiration. The right kidney could easily be felt. The ex- 
tremities were negative. There were no signs of any glandular en- 
largement, superficial or deep. The temperature on admission ranged 
between 102 and 104 4/5, pulse about 100, and respirations 20 to 32. 
The blood count showed 3,300,000 red blood cells, with 35 per cent 
hemoglobin; white blood cells 3,400; polynuclear 46 per cent; leuco- 
cytes 54 per cent. 

A blood culture, taken a short time after admission, showed what 
appeared to be a short chained streptococcus, and from this an auto- 
genous vaccine was prepared, and the patient received increasing 
doses with what appeared to be excellent results, for in 2 weeks his 
temperature had gradually come down to normal, and remained there 
for almost 3 weeks, when, without any apparent cause, it jumped to 
103, and thereafter remained above normal, ranging between 100° 
and 104°. The vaccine was discontinued shortly after, as 2 subse- 
quent blood cultures remained sterile. 

The course of the disease was uneventful, and marked only by 
progressive asthenia, anemia and emaciation, finally ending fatally 
3^ months after admission, on December 18. 

In view of the findings at autopsy, the symptom complex presented 
was peculiarly confusing, especially from the standpoint of the tem- 
perature course and the glandular involvement. 

The temperature course in Hodgkin's disease can be very variable, 
as is well known, but has been classified by Longcope 1 into 3 more 
or less distinct types: 

1. Mild and continuous, slightly irregular fever, varying a few 
degrees, rarely going above 101 or 102°. 

2. Temperature quite irregular, light and intermittent; and 

3. The relapsing type, a very unusual one, showing periods of 
pyrexia lasting several days or weeks, and alternating with similarly 
variable periods of apyrexia. 

While this last type was observed as far back as 1870 by Murchison, 2 

longcope: Bull. Ayer Clin. Lab., No. 1, 1903; N. Y. Path. Soc, 1908, N. 
S. viii, 153. 

2 Murchison: Trans, of the Path. Soc. of London. 1870, xxi, 372. 



126 ST. LUKE'S HOSPITAL REPORTS 

and again by Pel 3 4 , in 1885, Ebstein 5 in 1887, Ruffin 6 in 1906, and 
by a few others, it will be seen from the scarcity of the cases that it 
is by far the most unusual type, so much so that Ebstein considered 
the peculiar temperature course sufficient ground for a separate clas- 
sification, and called the disease "Chronic Relapsing Fever." 

While the present case was under observation for only part of the 
course of the disease, there were apparently 3 periods of pyrexia, and 

2 of apyrexia, the first of about a month, the second lasting almost 

3 weeks. 

The second and more unusual phase of this case was the distribu- 
tion of the glandular involvement. At no time in the course of the 
disease was there any enlargement of lymph nodes palpable, and 
at no time was there any enlargement of the deeper nodes, either by 
direct evidence, or by secondary pressure signs. The patient never 
suffered from any pain which might have been taken as sign of pres- 
sure on any nerve. There was no sign of any pressure upon the 
larynx, trachea, bronchi or esophagus, and so also, no dyspnea or dys- 
phagia. There was never any edema or evidence of ascites. By no 
physical signs in the chest could one assume the enlargement of any 
bronchial or mediastinal lymph nodes, and no amount of palpation 
could elicit any enlargement of the abdominal glands. There have 
been cases of Hodgkin's disease reported in which the deep glands 
were apparently the only ones involved, 7 but they seem quite regu- 
larly, at least in the later stages, to have given secondary signs of 
pressure, so notably absent here; and Reed, 8 in the comprehensive 
discussion of the disease, goes so far as to say, "We know of no case 
where the pathological anatomy was described in sufficient detail to 
permit of a positive diagnosis, in which the disease commenced else- 
where (than in the cervical region)." 

The blood findings in our case were interesting. While at the 
Loomis Sanatorium, in August, he first had 4,640,000 red blood cells, 
and in 2 weeks actually gained 700,000. On September 6, he had 
3,332,000, and 50 per cent hemoglobin. On September 23 he had 
3,500,000, and 50 per cent hemoglobin. Thus, in spite of fever, he 

3 Pel: Berliner Klin. Wochenschrift, 1885, xxii. 
4 Pel: Berliner Klin. Wochenschrift, 1887, xxiv. 
"Ebstein: Berliner Klin. Wochenschrift, 1887, xxiv. 
"Ruffin: Am. Journ. Med. Sciences, 1906, cxxxi. 
7 Stall: Medical Record, N. Y., 1905, Ixvii, 773. 
"Reed: Johns Hopkins Hospital Reports, 1902, x, 133. 



HODGKIN'S DISEASE 127 

gained in red blood cells and hemoglobin, but this may have been 
from blood concentration, and not a true numerical gain of cells. The 
resistance of the blood and general strength under such a high fever 
was, however, striking. The digestive ability was always good. 
Leukopenia was a marked and constant feature, the leukocytes were 
never higher than 6,500, and more often were between 3,000 and 
5,000 per cubic millimeter; the polynuclear and lymphocytes were 
variable, though in normal range proportions ; eosinophyles were not 
present. 

The clinical picture was extremely puzzling. Dr. O. D. Kingsley, 
of White Plains, who first treated him, thought of a tuberculous con- 
dition. The fever, night sweats and signs at the right apex at this 
period of his illness would seem fully convincing, but 8 months later, 
under the observation of Dr. H. M. King, at the Loomis Sanatorium, 
the diagnosis of pulmonary tuberculosis was abandoned, and he 
pointed out the necessity of investigation on other lines, and sent him 
to St. Luke's Hospital, with the suggestion that the spleen was at the 
bottom of it, and its removal might be considered. Under our in- 
vestigation a short chained streptococcus was found once in blood 
culture, and an autogenous vaccine was employed with prompt re- 
mission of his fever, followed by general improvement, but a return 
of fever after three weeks' remission without subsequent confirm- 
atory blood cultures, led us to believe that our previous positive cul- 
ture was a contamination. 

A few weeks before the patient's death, Dr. S. W. Lambert sug- 
gested the possibility of Ebstein's variety of Hodgkin's disease, but 
prominent clinicians, to the time of his death, were quite in doubt 
as to the true condition, and considered the probabilities of a cryp- 
togenic septicaemia, chronic miliary tuberculosis and multiple sarco- 
matosis. 

That such cases should be enigmas, is due in the first place, to their 
infrequency, but chiefly to the poor and meager description of their 
symptoms found in the text-books, which classify them as a variety 
of Hodgkin 's disease without pointing out their wide divergence from 
the ordinary clinical picture of that disease. The number of cases 
reported with long febrile periods with more than one remission, 
show clearly that we are dealing with a specific affection running a 
very definite clinical course. In the two cases which I have seen, 
this one, and one in consultation with Dr. Everett W. Gould, periods 
of pyrexia and apyrexia alternated, in neither case were the super- 



128 ST. LUKE'S HOSPITAL REPORTS 

ficial lymphatic glands implicated, but moderate splenic enlargement, 
with some involvement of the abdominal and thoracic glands, was a 
feature in both cases. 

This case resembles most strikingly, both in its relapsing tem- 
perature curve, as well as in the absence of any definable glands, the 
cases reported by Pel and Ebstein, in 1885 and 1887, one of which 
had as many as 9 periods of pyrexia, and which were considered by 
Pel to be pseudo leucemia, and by Ebstein, a new clinical entity. 

PATHOLOGICAL REPORT BY F. C. WOOD, M.D. 

The body is that of an emaciated young man of small frame. The 
skin shows a brownish tint. There is a decubitus ulcer over the sac- 
rum. On the anterior wall, over the left costal cartilage, there is a 
small nodule partially invading the cartilage about 1.5 cm. in di- 
ameter. The cut surface is mottled with yellow and white areas. The 
left pleural cavity contains about 150 c.c. of clear, straw-colored fluid, 
the right about 100 c.c. There is an old fibrous adhesion between 
the right lung and the thoracic wall. 

The lungs show considerable hyperstatic fluid and are deep red in 
the posterior portions. Microscopically, there is a little bronchial 
pneumonia. The right lung shows a scar at the apex, but no other 
evidences of tuberculosis. The bronchi contain a little thick, mucoid 
pus. 

The lymph nodes of the hyla are enlarged to a considerable mass, 
the individual nodes measuring 1 to 2 cm. in diameter. They are 
very dark in color and considerable fluid exudes on section. 

The heart shows no lesions except that the leaflets of the anterior 
and right posterior aortic cusps are united by a fibrous nodule about 
5 mm. in diameter. 

The spleen is large and soft, weighing 470 grams. The surface is 
irregular owing to the presence of small nodules underneath the 
peritoneum. On section nodules are found scattered throughout the 
organ. They are of opaque yellow color, irregular in outline, and 
measure from 5 to 10 mm. in diameter. There is one nodule which 
is much larger, measuring 4 cm., very soft and dark red. 

The kidneys show no lesions. The suprarenals, bladder, and other 
genito-urinary organs are normal. 

The mucous membrane of the intestine shows no lymphatic hyper- 
plasia. The stomach mucous membrane is destroyed by post-mortem 
digestion. 














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Fig. 1. — Nodule from liver. Case I. 
X 1000. 






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Fig. 2. — Nodule from spleen, sbowiug giaut cell. Case I. 
X 1000. 



HODGKIN'S DISEASE 129 

The mesenteric lymph nodes are moderately enlarged, measuring 5 
to 20 mm. in diameter. They are pale yellow in color, firm and homo- 
geneous on cut section. 

The liver weighs 2,240 grams. It is deep red in color, and scat- 
tered through the tissue are a large number of yellow, irregular 
nodules, 5 to 15 mm. in diameter. 

Scattered about the thorax and abdomen are a considerable num- 
ber of enlarged nodes, some lying along the aorta and the esophagus, 
others under the iliac vessels and in the inguinal region. They are 
rarely above 1 cm. in diameter. About the trachea, however, the 
nodes are considerably enlarged, measuring 2 to 4 cm., and form a 
nodular mass. The largest node measures 2 to 4 cm., and shows on 
section mottled areas of yellow and deep red color. There were also 
on the parietal pleura a number of small, yellowish nodules, which 
are firmly attached to, and in some cases extend into, the substance 
of the ribs. 

The thyroid shows no lesions. The bone marrow of the femur is 
a deep red in color in its upper third. The humerus contains red 
marrow in its middle portion. The marrow of the lumbar vertebrae 
is increased in amount and very deep red in color. The sternum and 
ensiform contain a considerable amount of reddish marrow. 

Microscopical Examination. — Study of the bone marrow from the 
femur shows a hyperplasia of all the elements, with many plasma 
cells and a large number of eosinophiles in the tissue. There are also 
many areas closely set with normoblasts, such as are seen in the severe 
anemias. Megakaryocytes are abundant. The whitish nodule in the 
sternal marrow shows areas of necrosis surrounded by fibrous con- 
nective tissue, which contains many large multinuclear cells, plasma 
cells, and numerous eosinophiles. The lesions in the lymph nodes are 
typical of those of Hodgkin's disease ; in other words, a fibrous hyper- 
plasia with disappearance of the normal lymphoid structure and the 
growth of many multinucleated cells. A moderate number of eosino- 
philes are also present. A similar picture is seen in the nodules from 
the liver. There were no evident nodules in the kidney. 

case 2. — hodgkin's disease complicated with diabetes mellitus 
cerrhosis of the liver. 

The patient, a male, of 39 years, was under observation in the 
hospital from September 25, 1911, to October 5, 1911. The reason 
for the patient's application to the hospital was that he had pain in 



130 



ST. LUKE'S HOSPITAL REPORTS 



the abdomen, swelling of the feet and legs, and cough. Of his family 
history, the only fact of importance was that his father died at the 
age of 72, having had diabetes. The patient had been well until 6 
years before his admission, at which time he developed diabetes, but 
improved under treatment. Some 3 years ago the glycosuria re- 



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HODGKIN'S DISEASE 



131 



noticed any blood. He began to be constipated and lost weight. 
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ago, when he noticed that his feet and ankles were swollen, and a little 
later his abdomen began to enlarge, and for the last 10 days he had 
not been able to walk. He had an annoying cough for about 4 Weeks. 
His shortness of breath had not troubled him much. 

Physical examination of the patient shows that he is a fairly well developed, 
poorly nourished man, with considerable jaundice of skin and sclerotic. He 



132 ST. LUKE'S HOSPITAL REPORTS 

has moderate dyspnea and is more comfortable sitting up, but be is not cyan- 
otic. Tbe pupils are equal and react to light. Tbere are no conjunctival 
hemorrhages. A few small lymph nodes are palpable in the neck. Tbe heart 
shows only a faint systolic murmur at the apex and soft systolic murmur over 
base. The second pulmonic sound is accentuated. The pulse is regular and of 
good force, and the vessel walls are not thickened. There is evidence of fluid 
in the pleural cavity, and a few rales can be heard in the lung. Tbe abdomen 
is moderately distended, there is edema of the abdominal wall and of the back, 
and a fluid wave is present. The liver and spleen are not palpably enlarged. 
There is marked edema of the lower extremities. In the left axilla there is a 
group of much enlarged lymph nodes. 

The day following admission, 8 ounces of fluid were removed from 
the abdominal cavity, and then the liver was found to be 3 inches 
below the costal margin. The spleen was just palpable. The urine 
was 1,024 acid, contained a trace of albumin, 2 per cent of sugar, no 
acetone, no acetic acid. The red cells were 3,900,000 ; hemoglobin 75 
per cent; polynuclears 72 per cent; lymphocytes 28 per cent. The 
patient ran an irregular fever. A few days after his admission, a 
lymph node was removed from the left axilla, measuring 2 x 2 x 1.5 
cm. Microscopical examination showed that the capsule of the node 
was intact, but the reticulum was largely converted into a fibrous 
tissue mass. The lymph structure was greatly diminished in extent, 
and many large cells with 5 or 6 nuclei were scattered in greater or 
smaller numbers throughout the fibrous tissue meshwork. Eosino- 
philes were not found. 

The patient's condition gradually became worse, and he died 10 
days after admission to the hospital. An autopsy was not obtainable. 



A CASE OF THROMBOSIS OF THE VERTEBRAL ARTERY. 

Henry S. Patterson, M.D. 

Of recent years, much interest has centered around the vascular 
accidents of the posterior fossa of the skull in general, and of the 
vertebral artery in particular. A number of cases of thrombosis of 
that vessel have been recorded in the literature of the subject, but 
as yet the symptomatology is sufficiently undefined to warrant a report 
of the following case : 

F. B., 52 years of age, married, housewife. Admitted to the hospital 
May 20, 1911. Chief complaint, inability to swallow. 

Present Illness. — Eight days previous to admission the patient became 
suddenly faint, and was obliged to sit down. When she attempted to drink, 
she found that she was unable to swallow, the fluid returning through the 
nose. She has had some slight numbness of the right side of the face. She 
has had no pain. She thinks that her hearing has not been good for the last 
few days. She has been gradually growing weaker, and has been obliged to 
take to her bed. 

Past Illnesses. — None but an attack of swelling of the legs and abdomen, 
six months ago, lasting seven weeks. Menopause five years ago. Seven chil- 
dren ; no miscarriages. 

Family History. — Negative. 

Physical Examination. — Large-framed, extremely obese woman, not acutely 
ill. Facies alcoholic. No icterus. Herpes on lips. Patient is conscious and 
rational, and speaks without difficulty, and distinctly. She is quite deaf in 
the right ear. She is apparently unable to swallow. The tongue is dry and 
coated, and does not deviate. The mucous membrane of the mouth is normal. 
The teeth are in very bad condition. The throat is red and congested. The 
tonsils are not enlarged. The muscles of the pharynx and soft palate are 
paralyzed on the right side. On phonating, the uvula and pharyngeal wall 
move to the left. No anesthesia of the pharynx. On swallowing fluid, it 
comes out through the nose, especially the left nostril. Very slight flattening 
of the left naso-labial fold. Patient says that sensation is more marked on 
the left than the right cheek. The right pupil is contracted; both react to 
light and accommodation, the left more actively than the right. 

Heart. — Apex impulse in the fifth space, 12 cm. to the left of the mid-line. 
Left border percusses 13 cm. to the left of the mid-line. Right border just 

133 



134 ST. LUKE'S HOSPITAL REPORTS 

to the right of the sternum. Action irregular in force and frequency. The 
first sound at the apex is valvular, and varies in quality. The second aortic 
is louder than the second pulmonic. Reduplication of the second sounds at 
the base occasionally. No murmurs. Pulse is rapid, and irregular in force 
and frequency, of poor size and force with increased tension. Vessel wall is 
palpable. 

Lungs. — Clear front and back, except for a few scattered subcrepitant 
rales. Breathing diminished over the bases behind. 

Liver. — Area of dulness not enlarged ; edge not felt. 

Spleen. — Area of dulness not enlarged; edge not felt. 

Abdomen. — Diastasis of the recti, with a large ventral hernia, showing 
impulse on coughing. No masses nor tenderness ; no ascites. Many old 
striae. 

Extremities. — No paralysis. Varicose veins over the lower part of legs, 
with scars of old ulcers. Slight oedema of the legs. Knee jerks present. 

The temperature was 98° F. on admission, and gradually rose until it 
reached 105.6° at death, on May 23d. 

The blood pressure ranged from 210 to 195 mm. of mercury. 

Two leucocyte counts gave the following: 16,000; polymorphonuclears, 83 
per cent ; red cells, 6,200,000 ; haemoglobin, 100 per cent. 

Urine : Sp. gr., 1,020 to 1,022 ; albumen, 15 to 20 per cent. No casts found. 

The patient gradually became weaker, lapsed into unconsciousness and 
coma, the temperature gradually rose, and death occurred on the fourth day 
of her stay in the hospital. From the sudden development of symptoms, and 
from the disturbance in the innervation of the right pharyngeal muscles, it 
was inferred tbat a hemorrhage had taken place into the nucleus of the right 
glossopharyngeal nerve. 



Extract from the notes taken at the autopsy 



There is considerable cedematous fluid filling the pial spaces of the sulci, 
which is most marked in the posterior fossa. The right vertebral artery is 
distended to a diameter of 4 mm. by a thrombus which extends from a point 
just below the basilar artery to the anterior condyloid foramen, and appar- 
ently beyond. It occludes the orifice of the posterior cerebellar artery. On 
sectioning the medulla, about the level of the olive, an area of softening is 
seen, which occupies the upper right portion of the section, and is about 
7 mm. in diameter. It includes the restiforme body, the upper portion of the 
olivary nucleus and the intervening structures. It extends up into the inferior 
cerebellar peduncle. A number of very small branches of the inferior cere- 
bellar artery pass into the medulla at the level of the softened area. The 
medulla, below this point, and the region supplied by the right inferior cere- 
bellar artery are normal. The cerebrum is normal. The ventricles are free. 



REPORT OF A CASE OF ACUTE ENDOCARDITIS WITH IN- 
FLUX OF ALL THE CHORD M TENDINE.E OF THE 
ANTERIOR CURTAIN OF THE MITRAL VALVES. 

Lewis F. Frissell, M.D. 

T. T., hotel manager, 52 years of age, married, was admitted to the med- 
ical ward of St. Luke's Hospital, July 5th, complaining of severe dyspnoea. 
Until eight weeks before admission, he felt perfectly well, but at that time 
noticed that his customary mode of life fatigued him and that he became 
short of breath on exertion. He has not noticed precordial pain or sudden 
exacerbation of symptoms. Gradually his dyspnoea increased, confining him 
to bed, and of late has amounted to orthopnoea. He has not been conscious 
of fever, but his wife thinks there has been some elevation of temperature 
in the last few weeks. 

There has been a little cough without expectoration. Urination frequent. 
His occupation required no severe physical work, and his habits were in- 
clined to be sedentary. 

Until the onset of his present trouble, he had been remarkably free from 
illness since his childhood, in which he had suffered from measles, scarlet 
fever, diphtheria and chicken-pox. No history of venereal disease or rheu- 
matic fever is obtainable. His personal habits are bad. He is a constant 
user of alcohol, five or six whiskeys or beers daily with periodic sprees. 

Tobacco is used in moderation. Coffee six cups daily. 

The family history is good; his father died of pneumonia and mother of 
apoplexy. 

Physical Examination. — Patient is a fairly well-developed and well-nourished 
man of 52 years, appearing moderately prostrated. There is some dyspnoea 
and orthopncea. No jaundice or cyanosis. Skin and mucous membrane 
somewhat pale. 

Eyes. — Pupils equal and react. Slight icteroid tinge to sclerse. 

Tongue.— Moist, not coated. 

Throat— Negative. 

Teeth. — In rather poor condition; a few missing. 

Neck.— Visible venous pulsation. 

Chest.— Well developed, expansion good. 

Heart. — Lifting impulse general over precordium. At apex region is a 
thrill, diastolic in time. Diffuse visible and palpable apex impulse in 5th and 
6th spaces 5% inches from m.l. Left border 6% inches out. Right border 2^ 
inches to rt. of m.l. At apex sds. are loud and booming in quality. At apex 

135 



136 ST. LUKE'S HOSPITAL REPORTS 

and heard over whole preeordium and transmitted to back is a loud systolic 
murmur, almost replacing first sd. This murmur has a maximum intensity 
at apex. To left of sternum in 5th space, murmur is almost musical in 
character. Within nipple and to sternum action of heart is gallop rhythm. 
Over base there is a soft systolic murmur. Both second sds. accentuated. 

Pulse.— Regular, small, fair force, vessel wall palpable. 

Lungs. — On right side posteriorly, beginning just below scapula, is slight dul- 
ness, increasing to base. At extreme base fremitus, voice and breathing 
sounds much diminished. An occasional rale heard at left base. Otherwise 
lungs are clear. 

Abdomen.— Lax; liver percusses to free border, edge not felt, but liver 
region is somewhat tender on pressure. Spleen not palpable. No dulness 
in flanks. No masses. 

Extremities.— Knee-jerks present. Considerable edema present. 

The day following admission there was noted a presystolic murmur of 
rather short duration but distinct crescendo character just within and above 
the apex, and at the apex a very faint diastolic murmur of a transitory 
nature as it disappeared not to reappear. 

The temperature was elevated, remaining between 102-101, the greater 
part of his stay in the hospital, but toward the end becoming subnormal. 

Repeated blood cultures failed to reveal the infecting organism. 

The physical signs in the heart did not change, though at one time the 
conduction time was increased owing to the effects of digitalis, and the sys- 
tolic murmur became more intense and musical. His hydrothorax and con- 
sequent dyspnoea were several times relieved by thoracentesis, but after a 
long illness the patient died October 5 of a terminal infarction of the lung. 

At no time did he complain of sudden, intense precordial pain, nor did 
his dyspnoea suddenly become aggravated. 

Autopsy, October 19, 1911, 2 P. M., by Dr. C. H. Bailey.— Body of well- 
developed but emaciated adult male. Marked edema of hands, legs, and de- 
pendent portions of body. Slight general jaundice. Pupils, 3 mm., normal; 
conjunctivae, yellow. 

Peritoneum.— About one liter of clear yellow fluid in abdominal cavity. 
Over anterior surface of liver, especially right lobe, are patches of firmly ad- 
herent organized exudate, also over surface of spleen, and a few patches on 
intestines. Firm adhesions join the omentum to the parietal peritoneum on 
the left side in the region of the splenic flexure and upper portion of the 
descending colon. 

Pleura.— Pleural cavities contain together 3,300 c.c. clear yellow fluid. 
Somewhat more in right than left. Left lung firmly adherent at apex. 

Lungs.— At the base of the right lung anteriorly is a roughly circular area 
of consolidation, about 3 cm. in diameter, deep red on section, slightly raised 
base surrounding surface and with fairly sharply defined outlines. 

A branch of the right pulmonary artery leading to the right lower lobe 
Is completely thrombosed. The thrombus extends from the root of the lung, 
where it protrudes into the auricle as a free tongue-like mass to the posterior 



RUPTURE OF CHORD.E TENDINE^E 137 

portion of the left base. It completely plugs the vessel, is a little more than 
1 cm. in diameter at its upper part, is grayish in color, with red mottling 
and generally firm, but in places softened. The whole lung, especially the 
base, is congested and edematous, but the tissue surrounding this vessel 
shows no sign of infarction. No thrombosed vessel is found leading to the 
area of consolidation in the anterior portion of right base already described. 

Left lung.— At left apex are two or three fibrous scars and one calcareous 
nodule about 2 mm. in diameter. On anterior edge of upper lobe, about 3 
inches below apex, is a roughly wedge-shaped area of consolidation, deep red 
on section, and with rather sharply defined limits. At its apex is a 
thrombosed vessel about 3 mm. in diameter. This thrombus is rather firmly 
attached to the vessel wall in places. A similar area is present in the an- 
terior edge of the lower lobe. 

Pericardium.— Contains about 50 c.c. of clear yellow fluid. On surface of 
heart are numerous large irregular whitish areas of organized exudate which 
are torn from the wall with some difficulty. The surface of these is generally 
smooth; one, about 2 cm. in diameter, on anterior surface of left ventricle, 
has an irregular, ragged surface. 

Heart.— Very large, 570 gms. weight. A tough grayish clot is firmly ad- 
herent to the musculi pectinati of the right auricle. Tricuspid orifice dilated, 
16.5 cm. Cusps normal. Pulmonary, 11 cm., normal. 

On opening the left auricle, the anterior cusp of the mitral, and its chordae 
tendineae, is seen protruding into the auricle, the latter having been torn from 
their attachment to the muscles. On the auricular wall, about 3 cm. above 
the auriculo-ventricular orifice, are a few small, rough, yellowish vegeta- 
tions. The mitral orifice measures 14 mm. The anterior cusp, all the chordae 
tendineae of which are torn from their attachment to the heart-wall, contains 
several nodular thickenings, but no recent process is apparent. The chordae 
tendineae attached to it are of apparently normal length, but enlarged, soft and 
yellowish in color, and appear to have been recently ruptured. At the sum- 
mit of the anterior papillary muscle is a small stump which was evidently 
the point of attachment of one of the broken chordae. There are two similar 
nodules in one of the cords of the posterior cusp near its attachment to the 
posterior papillary muscle. It is impossible to tell in the gross, whether 
these are vegetations or former points of attachment of the ruptured cords. 

The posterior cusp also shows numerous nodular thickenings. Two hard, 
calcareous nodules, one nearly a centimeter in diameter, are felt in the sub- 
stance of the cusp at its base. Over the larger of these, at the point of junc- 
tion of cusp and auricular wall, is a small depressed area with rough surface. 
Over the other nodules the endocardium is smooth and glistening. 

The aortic cusps are normal— 9 cm. Heart-muscle appears normal. Right 
ventricular wall measures 2 cm. Coronaries normal. 

Spleen.— 255 gms. On surface are several patches of firmly adherent or- 
ganized exudate. Capsule thickened. Very firm, deep red, trabecula 
prominent. 

Liver.— Greenish-yellow with thickly scattered deep red points ("nutmeg 
liver"). 



138 ST. LUKE'S HOSPITAL REPORTS 

Gall-Bladder.— Contains large amount of very thick greenish-red bile. 
Hepatic and common ducts admit passage of probe easily, and on dissection 
no calculi or other obstruction found. 

Pancreas.— Normal. 

Kidneys. — L. 195 gms., R. 195 gms. Capsules strip easily. Tissue slightly 
yellowish and opaque. Otherwise normal. 

Stomach. — Intestines normal. Bladder normal. 

Anatomical Diagnosis.— Chronic adhesive peritonitis; pericarditis; healed 
tuberculosis; double hydrothorax; thrombosis of branches of pulmonary ar- 
tery; infarction of both lungs; cardiac hypertrophy; acute endocarditis; rup- 
ture of chordae of anterior cusp of mitral; chronic passive congestion of liver 
and spleen. 

Bacteriological. — Culture from heart's blood: No growth. 

Microscopical. — Liver: Intense congestion about central veins with result- 
ing atrophy of liver cells in center of acini. Many of liver cells about these 
areas filled with dark pigment. 

Pancreas.— Slight increase of interstitial tissue. 

Kidneys.— Capillaries congested. A few sclerosed glomeruli. 

Pulmonary Artery. — Branch shows occluding thrombus of fibrin. It is ad- 
herent to wall in places. Degenerated in center. Undergoing organization at 
attachment to wall on one side. Another section shows occluding thrombus of 
large branch, extensively organized, except in center, which consists largely 
of red blood capsules. Surrounding lung tissue infarcted. 

Lung.— Area of infarction consists of extravasated blood and exfoliated 
cells of alveoli; over a large portion outlines of alveoli only roughly indi- 
cated by broken-down connective tissue septa. Many of the exfoliated epi- 
thelial cells of the air-vesicles are loaded with pigment. Two small vessels 
show partial obliteration of lumen by fibrin and red cells, partially organized. 

Heart. — Muscle, slight brown atrophy. 

Chordse tendineae show evidence of old chronic inflammation. 

The case presented is of unusual interest on account of the rarity 
of the lesion, its mode of production and the occurrence of a pre- 
systolic murmur in the absence of stenosis of the mitral valve. A 
review of the literature shows 50 reported cases, including 8 ruptures 
of papillary muscles, a synopsis of which is appended to the present 
report. Many of them are old, some in the days before the use of 
refined methods of physical examination, and even that reported by 
so great a master as Laennec is difficult of analysis, owing to the in- 
correct views obtaining as to the production of the second heart tone, 
so that his statement that "The contraction of the auricle as long as 
that of the ventricle donnait le bruit de sufflet" leaves one in doubt 
as to his meaning. Presumably, as he regards the second sound of 
the heart as synchronous in time with auricular systole, the murmur 
heard was diastolic in time. As regards the cause of the rupture, the 



RUPTURE OF CHORDS TENDINEiE 139 

tendency of the early observers is to lay stress on physical effort and 
trauma, though if the cases be analyzed, in many of them an endo- 
carditis was obviously present, as proven by vegetations or valve 
change, described in the autopsy reports. These changes were con- 
sidered by some to be secondary, but precisely on what ground it is 
difficult to see, except from the absence of symptoms prior to the 
trauma or strain. 

On dividing the cases as reported, it seemed wise to classify as 
follows : 

1. Those cases due to severe traumata, such as fractured ribs from 
violent compressions, falls from a considerable height, stab wounds, gun-shot 
wound, in one the kick of a horse. Of this group seven cases were found 
resulting in a tearing of papillary muscle rather than the chorda? themselves, 
these latter being due to stab and gun-shot wounds, and a fall from a win- 
dow, respectively. That trauma of such severity in the region of the pre- 
cordium could result in rupture of the chordae will, I think, be admitted with- 
out comment. 

2. Cases of ruptured chordae in which the rupture has followed efforts 
such as straining, lifting, excessive fatigue, severe cough, in which the 
autopsy disclosed no reported endocardial lesions in the heart. Of these five 
cases are reported of which two showed blood-vessel lesions, one an aortic 
aneurism, and the other coronary sclerosis. Two cases also showed papil- 
lary muscle rupture, leaving only one case of actual chordae rupture in hearts 
apparently free from any other lesion. This is the case of Dickinson. The 
patient, a young male, twenty-one years of age, had a severe pain under the 
left nipple while lifting a load of bricks, developed immediate signs of cardiac 
insufficiency and died in two months. Autopsy carefully describes the valves 
as normal, except for rupture of the chordae attached to the posterior cusp 
of the mitral valve. 

3. Cases of rupture said to be due to or preceded by strain, but in which 
endocardial or myocardial lesions were also found at autopsy. In this class 
nine cases are found. 

4. Cases of rupture of the chordae, in which endocardial lesion was 
found, but not following known history of strain or trauma. In this class 
are nineteen cases. Among these are a number in which no history was 
given or obtainable, these constituting a sub-class of mere pathological 
reports. 

5. Reported cases of rupture in which data given are insufficient to de- 
termine the probable cause in which no autopsy has been made and one 
("Gilbin") whose report was not accessible. In this class are ten cases. 

Obviously, the cases with pathological change in the heart vastly 
outnumber the cases without 28 to 12, and if we exclude the severe 
traumatic cases, we reduce this latter group to 5, which may be still 



140 ST. LUKE'S HOSPITAL REPORTS 

further reduced to 3 by excluding the 2 cases with vascular disease. 
Of the remainder, 2 are ruptures of the papillary muscle, leaving 
but 1 in which the chordae alone were ruptured. Over-strain alone 
would therefore seem to be an infrequent cause of this occurrence, 
unless we regard the rupture itself capable of secondarily causing 
an endocarditis. This is the position of de Quervain, who reports a 
case of malignant endocarditis following a sudden muscular exertion. 
This contention he supports by quoting the production of endocardial 
lesion in animals by damaging the valves mechanically. 

Experimental evidence of the difficulty of rupturing the healthy 
chorda? is afforded by Barie, who, while able to produce aortic rup- 
tures with pressures of 170-400 mm. of Hg, was able to produce rup- 
ture of the chordae in only one case, and that at 1,085 mm. of Hg., a 
pressure that is almost inconceivable in the ventricles, and which ap- 
parently, under experimental conditions, is more liable to rupture the 
heart-walls themselves than the chordae. The ordinary pressure in 
the ventricle is but slightly higher than the pressure in the aorta, 
which may be taken roughly as its measure, maximal 3-400 mm. 
Other authors, as Libman, report in cases of subacute endocarditis 
such as are caused by his streptococcus viridans, the not infrequent 
localization of vegetations on the chordae and occasional rupture, so 
that the number of ruptured chordae may be much greater than the 
reported cases indicate. 

It seems fair to assume, then, that the healthy chorda is rarely 
if ever ruptured by strain or exertion, and that a pre-existent endo- 
carditis is necessary to rupture. That effort may rupture a diseased 
chorda is obvious. From the examination, it is impossible, in the re- 
ported case, to state the date of the rupture of the chordae. Prob- 
ably, giving way one by one, the lesion dates from his onset of symp- 
toms, the gradual increase in symptoms being due to the increasing 
insufficiency of his mitral valve. 

The symptoms of such a lesion are, of course, outspoken signs of 
mitral insufficiency with signs of cardiac insufficiency in proportion 
to the number of chordae ruptured and the suddenness of the onset of 
leakage before the heart can accommodate itself. In a case where the 
patient is known to have had no cardiac signs, no enlargement of the 
heart murmurs or symptoms due to insufficiency, and where following 
a straining effort in which the intraventricular pressure may be as- 
sumed to be greatly raised, a sudden severe pain is felt or a feeling 
as of something having given way, followed by severe dyspnoea and 



RUPTURE OF CHORDAE TENDINEiE 141 

signs of mitral leakage, a rupture of this sort may properly be sus- 
pected. On the other hand, when without history of strain, a mitral 
leakage is found which gradually becomes worse owing perhaps to 
the consecutive giving way of the tendons, the lesion is indistinguish- 
able from an ordinary mitral insufficiency, and this will be the case 
in the vast majority of such ruptures. 

The origin of the presystolic murmur is less clear. Apart from 
complicating mitral stenosis or outspoken aortic insufficiency, but 
three instances are reported of a murmur occurring in diastole. The 
doubtful case of Laennec, previously alluded to, makes a fourth. One 
of these, that of Barie, may be attributed to the perforation in the 
aortic valve producing a Flint murmur. The other two occurred in 
cases where the papillary muscle was torn off, leaving the flap with 
its tendons and muscles free to travel between auricle and ventricle, 
respectively, in systole and diastole. The murmur was described, in 
one case, as a systolic and diastolic murmur ; in the other, as a murmur 
in time presystolic, but not having a true presystolic character. "It 
was not soft, nor was it a squeak." 

Our murmur was a fairly localized short murmur inside and above 
the apex, heard at times as far as the left sternal border, and though 
not intense, of a clearly rumbling, crescendo character. 

As the anterior curtain of the mitral valve swung free it must 
have traveled from auricle to ventricle with each diastole, and the 
sound may conceivably have been due to the vibrations set up, par- 
ticularly by the strong current of blood due to auricular systole. 
Much as a sail flaps in the wind when a fore and aft vessel comes 
about in a stiff breeze, so the increased strength of the blood current, 
at this period of the cardiac cycle, may readily cause a murmur in 
the heart due to the vibrations of the free flap. 

A second possibility is that the abrupt termination of its course 
from auricle to ventricle brought it up with much the effect of crack- 
ing a whip. 

SYNOPSIS OF PREVIOUSLY REPORTED CASES. 

By Portal: 

Observation concerning a case of rupture of two fleshy columns of the 
mitral valve. The lesion also involved the wall of the left ventricle. 

By Corvisart: 

Man 39 years of age, abuser of alcohol; transitory attacks of rheumatism; 
died soon after admission to hospital with symptoms of extreme dyspnoea. 

Autopsy findings: Protuberant vegetations on margin of mitral valve 
and on semilunar aortic valves. The segment of the mitral valve in front 



142 ST. LUKE'S HOSPITAL REPORTS 

of the aortic orifice was no longer attached by tendinous cords to the fleshy 
columns. The chordae tendineae were ruptured, or detached, and it was 
barely possible to trace two of these cords at the level of one of the fleshy 
columns. 

By Corvisart: 

Man, 34 years of age, injured himself in trying to move, unaided, a barrel 
of alcohol; suffered from cough and palpitation of the heart, mitral valve 
studded with soft vegetations. In the examination of the pillars which sup- 
port the mitral valve, two of them were seen to have been ruptured some 
time ago. The extremities of these two tendons were soft, smooth, and 
rounded at the site of rupture. It was not possible to locate on the border 
of the valve the exact spot where they must have been inserted before the 
rupture. 

By Corvisart : 

Courier, 30 years of age, was admitted to the hospital immediately after 
a horseback ride of one thousand miles, without any rest; he had crossed the 
Channel after this ride, and while at sea had felt a sudden great oppression, 
with haemoptysis. He died soon after admission, under symptoms leading 
prior to the autopsy to the diagnosis of an acute lesion of the heart, "un- 
doubtedly a rupture of one of its parts." The left ventricle contained one 
of the large columns which support the mitral valves, floating free in the 
ventricular cavity. It had ruptured at its base, evidently quite recently, and 
a small clot was found near the site of the rupture. 

By Laennec: 

Man, 35 years of age, was admitted to the Neckar Hospital in Paris, with 
a history of heart trouble dating five months back. Thrill 5, 6, 7 spaces. 
The contraction of the auricle as long as that of the ventricle "gave the bel- 
lows sound." Death soon after admission. 

Autopsy findings: The heart was enlarged, especially the left ventricle. 
One of the tendons which pass from the extremity of the columns to the 
free border of the mitral valve was ruptured towards its middle. The upper 
portion was smooth, and was folded under the mitral valve, but without ad- 
hesions. There were warty vegetations on mitral valve and left auricle. 

By Bertin : 

A consumptive girl, 22 years of age: a severe coughing fit led to rupture 
of one of the muscular columns in which the tendons of the tricuspid valve 
are inserted; at the autopsy this fleshy column was found to be broken, float- 
ing free in midst of the ventricular cavity. 

By R. Adams : 

Cheyne's case : A musician, 34 years of age, strong and well nourished, 
of irregular habits, was suddenly attacked with a very severe pain in the 
left side of the chest, about the precordial region. The condition became 
steadily worse, with edema of the lower extremities, digestive disturbances, 
dyspnoea, loss of strength, cerebral symptoms, and so forth. Death about 
two months after the onset of the symptoms. 

Autopsy findings: The most interesting feature consisted in the rupture of 
the chord;e tendineae which attach the left auriculo-ventricular valve to the 



RUPTURE OF CHORDAE TENDINEiE 143 

columnae carnese. This rupture concerned variable levels, four of these 
tendons being found floating by one of their extremities in the interior of the 
ventricular cavity. Excrescences on mitral and segmoid valves. 

By Marat: 

A man, 44 years of age, on laboriously rolling a very heavy barrel, sud- 
denly felt something snap in the back, and was attacked by dyspnoea and 
palpitation. Death twenty months after the accident. 

Autopsy findings: One of the columnse carnese at which the tendinous 
cords of the mitral valve are inserted, was entirely ruptured, and pulled 
out. The patient also had an aneurism of the aorta, but he had never 
before complained of disturbances, which did not begin until the painful sen- 
sation referred to above. 

By Nicod: 

Autopsy findings, in case of a woman who had suffered from two attacks 
of suffocation, the last terminating in death: Rupture of two fleshy columns 
of the heart, at a distance from each other, of unequal length, with a different 
coloration of the ends. 

By Legendre: 

Autopsy findings in the case of a man who died with symptoms of 
dyspnoea, soon after fracture of the ribs, from violent compression: On 
opening the left ventricle of the heart, a large fleshy column, with tendons 
passing to the posterior segment of the mitral valve, was seen to be entirely 
broken and curled up on itself, entangled in two of its tendons. 

By Prescott Hewitt: 

A boy of twelve years fell from a height and died four hours after the 
accident. Autopsy findings: No external lesion on thoracic wall. Peri- 
cardium intact. Ecchymosis at point corresponding to upper portion of in- 
traventricular septum; this bloody extravasate came from a small tear of the 
heart-wall which extended to the upper portion of the septum and established 
a communication between the two ventricles. Two columnar carnese in the 
left ventricle were torn. 

By Williams : 

Policeman, age 27 years, habitual user of alcohol, lost flesh and strength 
for two years. Three months ago, on quickly mounting stairs, felt a very 
sharp pain in epigastrium; some days later, edema of lower limbs, dyspnoea, 
etc. At time of admission, urine was scanty, blood-tinged, and slightly al- 
buminous. Heart hypertrophied. Auscultation: systolic murmur loudest 
under left breast. Death a few days after admission. 

Autopsy findings: The two mitral cusps were found to be thickened and 
ossified; the chordae tendinese, inserted at the anterior valve, were ruptured at 
unequal heights, and the fragments were lined with soft vegetations. Pos- 
terior cusp was ossified, and its chordae tendinese were agglutinated. 

By R. B. Todd: 

A man, 31 years of age, was admitted to the hospital, with general edema, 
enlargement of the liver, marked dyspnoea and frequent cough. History of 
a stab wound, three years previously, in right side of chest, below nipple. 
Death ten days after admission to hospital. Systolic murmur apex and base. 



144 ST. LUKE'S HOSPITAL REPORTS 

Autopsy findings: Other valves normal, but the tricuspid presented sev- 
eral interesting lesions. The anterior segment of the valve, namely that 
which separates the infundibulum from the auricular portion of the ven- 
tricle, was suspended free in the ventricular cavity, retaining its connection 
with the heart only at the level of the fibrous auriculo-ventricular orifice. 
All the fibrous cords, inserted at the valve, were ruptured at different heights, 
leaving a fringed valvular border. The fleshy columns in which the cords 
originate were contracted and showed the rudiments of the broken chordae 
tendinese. The extremities of the latter presented small bulgings, similar to 
those seen at the end of the nerves in an amputation-stump. 

By Gordon: 

A woman, 26 years of age, who had been admitted to the Whitworth 
Hospital with violent hsernoptosis. The diagnosis of rupture of the chordae 
tendinese of the heart was rendered, on the basis of the sudden and violent 
pain in the region of the heart, followed by intense palpitation and weakness, 
as well as the decided character of the bruit, and fremissement at the root 
of the neck. She lived ten days after her admission and then sank ; the im- 
mediate cause of death was pulmonary apoplexy. 

Examination showed very slight disease in the aortic valves; there was a 
sight deposit in the central valve. Several of the chordse tendinese of the 
anterior portions of the mitral valve were ruptured, and covered with a soft 
cheesy matter. There seemed to have been slight endocardial inflammation, 
followed by rupture of the chordse tendinese, and this by the effusion of 
lymph, which lay in great quantities loose in the ventricle. 

By Allix: 

A prostitute, 25 years of age, was admitted to the St. Jean Hospital in 
Brussels, having become unconscious a few instants before. Auscultation was 
impossible ; heart sounds were confused and arrhythmic, but accompanied by a 
distinct vibratory thrill. Patient died one hour after admission. Thrill 
marked. 

Autopsy findings: Trace of an old endopericarditis, marked hypertrophy 
of the left ventricle. On opening the cavities, it was seen that the chordae 
tendinese, passing from the summit of the principal left columna carnea to the 
free border of the anterior segment of the mitral valve, were ruptured in the 
middle; these tendons were very fragile and easily torn; their surface was 
found to present a large number of small, round, wartlike vegetations. 

By Charles A. Lee: 

Man, age 65 years, while driving a stake into the ground with a heavy 
piece of wood, felt something give way suddenly in the region of the heart, 
and immediately fell to the earth, gasping for breath, and laboring under ex- 
cessive pain and dyspnoea. He never was well again, but lived for about ten 
months afterwards, with increasing symptoms of heart disease. 

Autopsy: The endocardial membrane was much thickened from chronic 
inflammation; organized lymph was deposited beneath it. Several of the 
chordse tendinese of the mitral valve had evidently been ruptured, as only 
their shriveled remains were visible, while others, both of the tricuspid and 
mitral, were so contracted and adherent to each other as to contract the cir- 



RUPTURE OF CHORDAE TENDINEAE 145 

cumference of the valves to such an extent as almost to close their orifice, 
and, of course, to prevent entirely their healthy play. 

Blakiston found the chordae tendineae shortened in 20 out of 46 cases of 
tricuspid regurgitation. In one he says, "One of the chords had apparently 
been broken, and was curled up into a nodule, like a pin's head" (p. 291) 
(cit. Lee). 

By Austin Flint: 

Woman. 35 years of age, who had suffered for some years from heart 
disease. "The interesting point connected with the specimen is not the con- 
traction of the mitral orifice, which is common enough, but the presence of 
two vegetations of considerable size, one as large as a bean, the other some- 
what smaller. The larger one is attached to the papillary muscle of the 
inferior curtain by what appears to be a small pedicle, which is a fractured 
extremity of one of the tendinous cords. The other concretion is upon an- 
other tendinous cord which has not been fractured. 

By van Giesen : 

Man, aged 24 years, was admitted to U. S. Naval Hospital, and presented 
hypertrophy of the heart, with tumultuous action, and a murmur with the 
first sound transmitted along the course of the aorta. Gradual aggravation, 
death about six months later. 

Autopsy findings in heart : On opening the left ventricle, the aortic valves 
are found to be thickened, contracted and studded with tenacious, fibrinous 
vegetations. The anterior portion of the mitral valve is also covered with sim- 
ilar vegetations. The chordae tendineae of the anterior portion of the mitral 
valve are all ruptured, shortened, and covered with tenacious, fibrinous effu- 
sion. The free extremities, which are expanded into small bean-shaped bodies 
when drawn with moderate force toward their original muscular attachment, 
will not meet by about a quarter of an inch. The chordae tendineae of the 
remaining portions of the mitral valve are healthy, presenting no traces of 
atheroma or ulceration. 

Dr. Stokes (cit. v. Giesen), in his work upon Diseases of the Heart and 
Aorta, details a case, extracted from the records of the Pathological Society, 
which in many respects is similar to the one observed by v. Giesen : 

"The cords of the anterior portion of the mitral valve were all broken 
across near to the fleshy columns; they were thickened, softened, and cov- 
ered with beads of very soft lymph." 

By J. Pollack: 

A woman, 42 years old, was admitted to King's College Hospital with 
severe pain palpitation, dyspnoea, and haemoptysis. Dr. Johnson diagnosed 
rupture of one or more of the chordae tendineae of the mitral valve. 

Post-mortem examination of heart: The pericardium contained four ounces 
of serum. The heart was large, the left ventricle being hypertrophied more 
than the right. One of the chordae tendineae of the mitral valve was rup- 
tured. Mitral valve was diseased, and the orifice contracted. Aortic valves 
much thickened. 

By Kelly: 

Description of specimen derived from a woman aged 49 years. Symp- 



146 ST. LUKE'S HOSPITAL REPORTS 

toms of heart disease for about two months prior to death. Autopsy: Left 
ventricle somewhat dilated, aortic valves healthy, slight atheroma of ascend- 
ing aorta. The anterior curtain of the mitral valve was fringed on the auric- 
ular side with some fibrinous beads, and some were found on the tendinous 
cords also. The posterior curtain was found lying loose; all the chordae 
tendineae were ruptured, and many were much shorter than usual ; some had 
a small bead of fibrin on their free extremity; all broke off close to a 
fibrinous deposit. It is probable that they were not all ruptured at once, as 
in some the fracture seemed quite smooth, while in others there was a little 
fibrin on the free extremity. 

By Dickinson : 

Patient, male, age 21 years. Perfectly well until four months previously, 
when he suddenly felt pain under left nipple whilst lifting heavy loads of 
bricks. Unable to work since, became worse in hospital, and died after two 
months. 

Diagnosis of laceration of chordae tendineae in mitral valve was confirmed 
by autopsy findings. The chordae tendineae attached to the lower edge of the 
posterior flap of the mitral valve were all broken close to their insertion into 
the fleshy columns, excepting that one or two cords remained entire at one 
corner of the curtain. A solitary tendinous cord, which was attached at the 
base of the flap near its center, remained entire. The segment of the valve 
of which the cords had been broken, appeared to have lost all valvular action, 
and must have swung uselessly from its base. The broken cords hung with 
loose ends, which had become somewhat thinned. The free edges of the 
mitral valve had become somewhat thickened and opaque. 

By Bristowe: 

Patient, man, age 62 years, died under symptoms of heart disease, which 
came on almost suddenly about three weeks before his admission to hospital. 

Autopsy findings: One of the tendinous cords attached to the posterior 
flap of the mitral valve was ruptured, the cord was much swollen, and of 
an opaque yellow tint; this change was most marked in the situation of the 
rupture. The lower portion of valve was dilated into a pouch and had a 
deep rugged notch. Mitral was normal in all other respects. Aortic valve 
was perfectly healthy. Coronary arteries, calcareous. 

By Hanot: 

The patient, a man, 37 years of age, was admitted with all the signs of 
mitral insufficiency: systolic murmur at apex, edema of lower limbs, enlarged 
liver, signs of bronchitis, etc. After three weeks' stay in the hospital, he was 
suddenly attacked by oppression and breathlessness; the face was livid, the 
body covered with clammy sweat; irregular heart-action, rapid death. 

Autopsy findings: Aorta, intact; valvular lesions of mitral valve; also 
three valvular tendons, about one centimeter long, whitish and thickened, 
were found to be ruptured and floating in the ventricular cavity. 

By Le Piez : 

A woman, 24 years of age, died suddenly (in syncope) on getting up out 
of bed, a fortnight after the onset of symptoms pointing to heart disease (no 
abnormal sounds in heart). At the autopsy, the heart-wall was found to be 



RUPTURE OF CHORDS TENDINE^] 147 

friable and in a state of fatty degeneration. One of the fleshy columns of 
the heart was ruptured, cut in two, at the junction of the two lower thirds 
and the upper third. The segment, where the chordae tendineae are inserted, 
was displaced between the two mitral valves. One rather large-sized ten- 
dinous cord was completely ruptured; it did not belong to the ruptured 
column. 

By Gilbin: 

Personal observation of a case of rupture of the tendons of the mitral 
valve. Records not accessible. 

By A. W. Foot: 

Man, aged 23 years, who had died suddenly while in the act of getting into 
bed. (All the physical signs of regurgitation through the mitral valve had 
been present.) The cords, which were found broken across about the middle 
of their course, were two or three of those attached to the musculus papil- 
laris, which regulates the larger curtain of the mitral valve, and were those 
nearest to that portion of the curtain which is adjacent to the interventric- 
ular septum. The broken cords were studded with warty nodules of fibrin ; 
both the ventricular and auricular surfaces of the principal curtain of the 
valve were covered with vegetations of a similar character, and continuous 
with those creeping along the chordae tendineae. 

By Willard Parker, 1859: 

The patient lived several years, suffering with heart disease. There were 
also fibrinous granulations upon the cords. 

By Willard Parker: 

Sudden rupture of the chordae tendineae, while running to a fire. Death 
occurred a few months afterwards. 

By J. C. Dalton, 1859: 

A man. aged 40, whose previous history was unknown, was found in his 
room comatose and died one hour later. 

Autopsy: The mitral valves were covered with several small vegetations. 
Two of the tendinous cords attached to the inner portion of the anterior cur- 
tain of the valve were ruptured. 

The rupture was at the point of attachment of the cords to the valve. 
The free ends of the cords were covered with fibrin, giving them a bulbous 
shape. 

By Alonzo Clark: 

There were vegetations on the broken ends of the cords, and upon the 
valves connected with them. There were vegetations on the cords of three 
or four other specimens which had been presented to the Society. In one 
case there was a thinning of the cords, ending in rupture; in other cases, 
the cords were thickened, but softened. Chordal inflammation is apt to 
be followed by vegetations, softening, and rupture. 

By J. T. Metcalf: 

Man, age 23 years, became rheumatic after an injury to the side and ex- 
posure to cold; developed dyspnoea, edema of face, ascites, anasarca. Rough 
systolic murmur over mitral valves, effusion into pericardium and both 
pleurae; albuminuria. Death from exhaustion. 



148 ST. LUKE'S HOSPITAL REPORTS 

Autopsy: Several chordae tendineae were ruptured. The aortic valves were 
studded with fibrin and insufficient; there was a large white clot in the 
heart. 

By Lionville: 

Case of an old woman, in whom the columns of the mitral valve were 
ruptured in consequence of a fall from a window on the third floor. 

By Terrillon : 

Man, age 48 years, gun-shot wound of chest, penetrating the seventh rib; 
death twelve hours later. Autopsy showed extensive ecchymoses in the peri- 
cardium and myocardium of the anterior wall of the left ventricle; no solu- 
tion of continuity; rupture of individual trabecules and mitral tendons. 

By Potain cit. Barie. Revue de Medicine, 1881, p. 318. 

A young woman died rapidly, in the Petie Hospital of Paris, under symp- 
toms which were referred to puerperal endocarditis. At the autopsy, all the 
tendinous cords of the flaps of the mitral valve were found to be ruptured, 
so as to produce a true acute insufficiency. 

By BariS: 

Woman, age 56 years; history of articular rheumatism, followed by symp- 
toms of heart disease; mitral systolic murmur; thrill, death one week after 
admission to hospital. Autopsy: Heart not enlarged, cavities small, walls 
of left ventricle slightly thickened. The mitral valve was whitish and some- 
what thickened; on testing with water, it was found that the posterior valve 
did not fit against the anterior valve, but floated in midst of the fluid, in 
consequence of rupture of four of its tendons. These tendons were broken 
about the level of their middle portion; they were somewhat thinned, but 
on examination presented no inflammatory changes. The aortic valves were 
normal. The tricuspid valve was intact and sufficient. 

By Potain: 

Rupture des tendons de la valvule mitrale. L'Union Midicale, 1891, p. 279. 

Man, 72 years of age, who had died with symptoms of mitral insuffi- 
ciency; the autopsy showed the presence of rupture of one of the tendons of 
the great mitral valve. The tendon had given way close to its insertion, 
and either floated in the ventricle, or became interposed between the flaps 
of the valve, preventing their accurate junction, and giving rise to intermit- 
tent mitral insufficiency. 

By C. W. Sharpies: 

Laborer; systolic and presystolic murmur, latter not characteristic in 
quality. 

At the autopsy of a man 45 years of age, there were found lesions of 
auricular endocarditis, and a rupture of the chordae tendineae, which were 
changed in appearance and character, being all that were attached, most 
anteriorly and nearest the center of the valve, with only one remaining on 
the left; thus leaving the valve to flap back and forth without its normal 
control. The longest chordal fragment on the valve was three-fourths of an 
inch long. It was softened, thickened, and beaded, smooth over most of its 
length, with one hanging vegetation. Attached to another broken chorda 
was a mass half an inch long and one-eighth in diameter, fastened by a 



RUPTURE OF CHORDAE TENDINESE 140 

narrow, small, short pedicle. Otherwise it was free to flap about in the 
ventricle. The other chordae presented no peculiarities, except that they 
were thick, soft, and very friable. One of the transverse bands connecting 
two chordae near their origin presented a large vegetation. 

By Degny Huchard : 

Man, 42 years of age, mitral insufficiency, also aortic insufficiency. 
Autopsy: The tendinous cords inserted at the posterior pillar (angle of sep- 
tum and ventricular wall) were adherent to the posterior commissure of the 
great mitral (cardio-aortic) valve. These parts were rigid and calcified, on 
one arterial surface. Analogous lesions were noted at the summit of the 
anterior pillar and the anterior commissure of the great mitral valve and 
the connecting chordae tendinese. But here the chorda? tendinese were rup- 
tured, one large tendon in particular being broken off about one centi- 
meter from its insertion at the valve, so that this anterior portion of the 
great mitral valve, being free from all tendinous chords, had become dis- 
placed upwards, into the left auricle. Only the presence of the rigid calci- 
fied tendon stump, which remained adherent to the great valve for about 
one centimeter, caused the luxation of this portion of the valve to remain 
stationary. The rigidity of the chorda? tendinese in front, opposite the small 
valves, acted like a rigid body placed crosswise, and prevented the great 
valve from resuming its normal position. 

By Halle: 

In the case of a man 63 years of age, who had died from broncho-pneu- 
monia, after suffering for two months from symptoms of heart disease, the 
autopsy showed the rupture of several tendons and chorda? tendinea?, on 
the left pillar of the mitral valve; two of these small tendons floated free 
in the auricle. 

By Poupon : 

Man, 41 years of age, who had died rrom a ruptured gastric ulcer; the 
mitral valve was found to be insufficient and the seat of peculiar changes. 
A softened vegetation, probably a band attached to the lower border of the 
anterior pillar, floated free in the cavity, toward the cardiac apex, and 
therefore in the direction of the blood-stream. The flaps of the mitral valve 
were extremely thick and hard, with scattered calcified spots. The an- 
terior pillars of the second class were connected by fibrous bands; one of 
these pillars presented an ulcer, with calcified margins. All the constituents 
of the mitral valve and its pillars were considerably hypertrophied. 

The emboli found at the autopsy were attributed to the rupture of a 
tendinous band of a pillar of the mitral valve; the band itself was inter- 
preted as the result of an old endocarditis. Murmur at apex. Time not de- 
termined. 

By Henry : 

Rupture of the posterior papillary muscle, 2 cm. in length (one in thick- 
ness), of the mitral valve, in a young robust male, known to be in good 
health two years previously. Death after about eight months, after transi- 
tory improvement, following upon traumatism (a kick from a horse) directly on 
precordium. The clinical picture showed a complicated recent cardiac af- 



150 ST. LUKE'S HOSPITAL REPORTS 

fectlon, with the sole symptoms of diastolic-systolic murmurs and dilated 
heart (ox-heart), which were explained by the free floating papillary muscle; 
this hung suspended from the chordae tendineae, and was necessarily thrown 
constantly from the ventricle into the auricle, and back again through the 
blood-current and the cardiac contractions. 
By de Quervain: 

Man, age 35 years, in good health, experienced a sudden painful sensa- 
tion In the chest, when holding up a very heavy barrel; this was followed 
by epistaxis and bloody expectoration. Later, cyanosis, increased frequency 
of pulse-rate, and cardiac distress. No findings early on auscultation, but 
three weeks later, a rough systolic murmur was heard at the mitral valve. 
The general condition became worse, and seven weeks after the accident, 
the patient died with symptoms of cerebral embolism. 

Autopsy findings: Circumscribed thickenings at free margins of anterior 
mitral flap, 1% cm. long, 1 cm. wide, irregular and friable. The valve in 
this area presented no chordae tendinese, but there was the stump of one. 
Microscopically, the thickening was interpreted as a fresh endocarditis pro- 
liferation, in part ulcerative in character. 

By Schmidt: 

A man 85 years old fell out of the window, from the second floor, land- 
ing on the left side of the thorax. 

Autopsy findings in heart: Posterior aortic valve presented a rupture 
through its entire thickness. There was also a tear 2 mm. long at the 
lower surface of the anterior mitral flap. The simultaneous rupture of the 
mitral valve is explained by the author in such a way that after the aortic 
rupture, the sudden back-flow of the aortic blood struck the open mitral 
valve, thrusting it up, and partly tearing it away from its support, the 
chordae tendinese. The rupture had occurred immediately above the inser- 
tion of a tendinous cord of the second class, which is inserted at some 
distance from the free margin, on the surface of the valve. Otherwise the 
mitral valve and its tendinous cords, as well as the right-sided valves, were 
unchanged. The heart was slightly atrophic; no degeneration of the 
myocardium. 

By Buchanan : 

Male. Symptoms, cardiac insufficiency with fever four years before. 
Systolic murmur over cardiac area toward axilla over vessel of neck. 

Autopsy: Mitral admits 3 fingers; anterior curtain presents an irregular 
fringe of ruptured chordae, 8 in number. Free extremities bulbous and 
granular from endocardial thickening. One papillary muscle, soft, pale, atro- 
phied, is completely severed from tendon. A few vegetations on margin of 
curtain freed by rupture. 

By Hawthorne : 

Male. Gave up rowing three years before death on account of "weak- 
ness." No definite mitral insufficiency. Presystolic thrill and murmur at 
apex. Systolic over whole precordium. 

Autopsy: Mitral stenosis. Anterior flap projects into and half closes 



RUPTURE OF CHORDAE TENDINE^J 151 

orifice. Three tendons are torn. Endothelium granular and swollen. Free 
edge of curtain studded with vegetations. 

By Barie : 

Case showing presystolic thrill and presystolic and systolic murmur at 
apex. Also diastolic at base. 

Autopsy: No mitral stenosis. Two chordae of anterior valve ruptured, 
mitral calcareous. Hole in posterior cusp of the aortic valve. 

By Gordon : 

Not accessible. 

By Jayle: 

Systolic murmur at apex. 

Autopsy: Rupture of the tendon at anterior flap. 

By Norris: 

Signs of mitral disease following lifting effort. Examined before; no 
signs. After systolic murmur at apex. Suspicion of presystolic. 

Diagnosis made of ruptured chordae. No autopsy. 

BIBLIOGRAPHY. 

Portal. Acad. Sciences, 1784. 

Corvisart. Essai sur les maladies du coeur, 1811. Lection. P. 218. 

Corvisart. Ibid. P. 267. 

Corvisart. Ibid. Observation 40, p. 263. 

Laennec. Auscult. Mediate, T. II, p. 626 (1819). 

Bertin. Trait6 des Maladies du Coeur et des Gros Vaisseaux. Paris, 1824. 

R. Adams. Dublin Hospital Reports, 1827, p. 404. 

Marat. Journal de M6d. Contemp., T. VI, p. 587. 

Nicod. Jour. Hebdom. des Progres des Sciences Med., IV, 1834, p. 42. 

Legendre. SocietS Anatom., 1839, p. 195. 

Prescott Hewitt. London Medical Gazette, 1847. 

Williams. London Medical Gaaette, 1847. 

Todd, R. B., Dublin Quarterly Jour, of Medicine, 1848. 

Gordon. Dublin Medical Gazette, I, 1854, p. 123. 

Allix. Annales Societe anat. patholog., Bruxelles, Vol. I, 1859. 

Lee, Charles A. American Medical Gazette, Vol. XI, Sept., 1860, p. 641. 

Blakiston. P. 2911 (cit. Lee). 

Austin Flint. N. Y. Med. Times, March 29, 1862. 

Ransford E. van Giesen. The Medical and Surgical Reporter, Vol. VIII, 
1862. 

Dr. Stokes. Diseases of the Heart and Aorta (cit. v. Giesen). 

Pollock, J. Transactions of the Pathol. Society of London, Vol. 16, 1865, 
P. 82. 

Kelly. Trans. London Pathol. Soc, XX, 1869, p. 153. 

Dickinson. Trans. London Pathol. Soc., XX, 1869, p. 150. 

Bristowe. Trans. London Pathol. Soc., 1873, p. 22. 

Hanot Soci6t6 Anatomique, 1879, p. 867. 

Gilbin. These de Paris, 1873. 

Le Piez. These de Paris, 1873. 



152 ST. LUKE'S HOSPITAL REPORTS 

Foot, A. W. Dublin Journal of Medical Science, Vol. 58, 1874, p. 254. 

Willard Parker, 1859. Trans. N. Y. Pathol. Soc, I, 1876, p. 98. 

Willard Parker, 1849. Ibid. 

Dalton, J. C. Trans. N. Y. Pathol. Soc., I, 1876, p. 97. 

Alonzo Clark. Trans. N. Y. Pathol. Soc, I, 1876, p. 98. 

Metcalf, J. T. Trans. N. Y. Pathol. Society, I, 1876, p. 97. 

Lionville. Mem. Med. Milit, 1878, p. 377. 

Terrillon. Le Progres Medical, 1879, p. 237. 

Potain, cit. Barie, Revue de Medicine, 1881, p. 318. 

Potain, Union Medicale, 1881. 

Baric Revue de Medicine, 1881. 

Potain. L'Union Medicale, 1891, p. 277. 

Sharpies, 0. W., Medical News, March 12, 1892, p. 295. 

Huchard, Degny. Journal des Praticiens, 1898, p. 164. 

Halle. Journal des Praticiens, 1898, p. 143. 

Poupon. Bulletins de la Soc. Anatom. de Paris, 1885, 7, 201. 

Henry. Korr. Blatt fur Schweizer Aerzte, Vol. 37, 1907, p. 761. 

de Quervain. Semaine M6dicale, No. 21, 1902, p. 169. 

Schmidt. Miinchener Med. Wchschrft, No. 38, 1902, p. 1565. 

Buchanan. Glasgow Med. J., 1894, XLII, 65-67. 

Hawthorne. Glasgow, Med. J., 1894, XLII. 

Barie. Rev. Med. de l'Est Nancy, '85, XVII, 374-378. 

Gordon. Proc. Path. Soc, Dublin, 1875. 

Jayle. Bull. Soc. Anat. de Paris, 1893, LXVIII, 170-172. 

Norris. International S. J. M. & S., Melbourne, 1894, T. 242. 



A REPORT OF TWO UNUSUAL CASES OF SEPSIS. 
Lewis F. Frissell, M.D. 

S. H., boy, 12 years old, was sent to the hospital July 12th, with a 
diagnosis of appendicitis. He had been a Boy Scout, and was per- 
fectly well up to July 9th, in camp. On this date he had had some 
altercation with the other boys and thinks the parts in the neighbor- 
hood of the root of the penis were injured. Since that time he has 
felt weak and has had pain in the right inguinal region, low down. 
He was nauseated and vomited several times. 

There had probably been fever for some time, as patient on ad- 
mission was irrational and his history is not dependable, that of the 
trauma being due possibly to a delusion arising from catheterization. 
His admission temperature was 1$5 2/4, P. 100, P. 28. When first 
seen in consultation on the surgical division, at the request of the at- 
tending surgeon, the boy looked acutely ill, and presented, on physical 
examination, no focal symptoms beyond acute local tenderness in the 
right groin, apparently maximal at a point just to the right of the 
symphysis pubis. This, with an enlarged spleen and one or two 
erythematous spots on the abdomen, were all that could be found. 

Evidence of wounds, trauma, pus pockets around the teeth, tonsils, 
or ears were not present. 

A blood culture was taken and positive diagnosis withheld. 

Two days later, on July 15th, he was admitted to the medical ward. 
The complete physical examination follows. 

The patient is an undersized, fairly well nourished boy of 12 years, appear- 
ing acutely ill. There is no dyspnea, cyanosis or jaundice. The skin and 
mucous membranes are of good color. He is slightly irrational ; muscular 
tremor of hands and arms. On turning in bed, he moves slowly and carefully, 
as if motion were painful. Patient is generally hypersesthetic. 

Eyes.— Pupils equal and react to light and accommodation. Tongue dry, 
coated, tremulous. 

Throat.— Tonsils are slightly enlarged. Neck, sub-maxillary gland on left 

153 



154 ST. LUKE'S HOSPITAL REPORTS 

side of jaw palpable; no other glands enlarged. Chest, fair development and 
expansion. 

Heart. — Visible apex beat in fifth space, 3 inches from mid-line. Left 
border, 3% inches. Right border, 1 inch to right of mid-line. Sounds of 
good quality, no murmurs heard. Second sound loud and snapping. Pulse 
regular, good force, vessel wall not thickened. Lungs clear. Abdomen, 
even contour, not soft, no rigidity made out. Spleen, sharp edge palpable 
1 inch below costal margin in nipple line. No abdominal tenderness. There 
is marked tenderness to gentle pressure on the rim of pelvis just to right 
of symphysis. An inguinal gland is palpable on right side, smaller one to 
left. 

Extremities.— K. J. present. Kernig's sign present. Babinski's absent 
Abduction of right leg causes pain, but not flexion or rotation. 

The elbow of the right arm is swollen, red and tender; there is limitation 
of motion, due to pain. On the outer edge of hand is a small pustule. 

Rectal Examination.— There is tenderness on right side at the line of the 
pelvis; the sharp edge of rim is not felt as plainly as on the other side. 

Eye Grounds.— Normal. 

Ears.— Normal. 

Urine. — Acid 1,020 ; alb. trace sugar ; few granular casts. Leucocytes 13,- 
000, P. 75%. Widal negative. 

In 48 hours there had developed an inflamed joint and a pustule; a ten- 
tative diagnosis of septicemia was made. 

July 16.— Right ankle and left hip involved; another pustule developed 
on shin. The heart showed a systolic murmur over the pulmonary area. 
There was some rigidity of neck. 

Lumbar puncture; no increase of pressure; fluid clear; few cells; all 
lymphocytes. 

July 18.— Culture from pustules shows staphylococcus aureus. Report of 
blood culture shows staphylococcus aureus; spinal fluid shows no growth. 

The temperature has been high, 101-104°, without chills, perspiration or 
extreme variations. 

The right ankle joint was opened and treated surgically. 

On July 28, an extensive urticarial eruption appeared on the chest and 
abdomen, and the autogenous vaccine treatment stopped in consequence. 

July 29.— The urticarial eruption has disappeared, but on right chest and 
in axillary region and along right costal margin are large hemorrhagic 
spots. 

Heart. — A soft systolic murmur has appeared at the apex, transmitted to 
the axilla. 

Death occurred on August 1. 

The entire case presents the appearance of a malignant sepsis, 
the main interest being the site of the original focus. 

The arduous life of a Boy Scout in camp precludes the possibility 
of an acute septic process before July 9th, and, while the heart valves, 



MALIGNANT SEPSIS 155 

of course, may have been involved from the start, evidence of old 
valvular trouble was lacking. 

If the boy's tale of maltreatment, told in delirium, be true, this 
may account for the localization of the process in the os pubis, the 
infection being caused by some wandering staphylococcus. 

Case 2.— M. M., 44 years, housekeeper. Patient was admitted to the 
ward July 23, 1911. At the time of admission she was irrational. Her 
history, in consequence, was not to be depended on. From members of her 
family an incomplete anamnesis was obtained. Since infancy she had suf- 
fered from some paralysis of the left side, which had caused a limp and a 
deformity of the fingers of the left hand, which, however, was not func- 
tionless. 

Otitis media of right ear for years. Date of original trouble unknown. 
It probably followed an attack of measles, which occurred in childhood. 

Six weeks ago the patient complained of severe pain over left gluteal re- 
gion, running down the posterior aspect of the thigh as far as the knee. The 
continuation of this pain caused her to go to bed 4 weeks ago, and a diag- 
nosis of "sciatica" was made by her physician. It is not known whether 
or not there has been fever, but patient has been thirsty. Two days before 
admission she complained of pain over the other sciatic nerve, and her 
mental condition became cloudy. Mentality is said to have been good 
previously. Increased frequency of urination during the past 2 days. The 
temperature was continuously high, running regularly from 101-105°. 

Patient is a poorly developed, emaciated, middle-aged woman, at times 
irrational, who lies in bed with elbows and knees flexed. Patient mumbles 
incoherently, but will answer simple questions in a thick voice. The eyes 
are sunken and the face has an anxious expression. The respirations are 
rather shallow and somewhat irregular. There is no dyspnea, cyanosis or 
jaundice. Skin and mucous membranes are pale. 

Eyes.— Pupils equal and react. 

Tongue. — Dry, coated with brownish material. 

Throat— Dry, coated with brownish material. 

Teeth.— Gums and lips covered with sordes. Teeth in poor condition. 

Neck.— No glands palpable. No neck rigidity. 

Chest.— Poor development and expansion. 

Heart.— Apex impulse seen and felt in fifth space, SV 2 inches from median 
line. At the apex there is a very slight thrill, systolic in time. Left border, 
4 inches out. Right border, under sternum. At apex the sounds are loud 
and forcible, first sound somewhat impure. No murmurs heard. Action 
regular. Over the base there is a soft systolic murmur. The second aortic 
is slightly accentuated. 

Pulse.— Regular, medium size, fair force, vessel wall moderately thickened. 

Lungs.— Hyperresonant note everywhere. Breathing sounds are faint on 
account of shallow respirations. On right side of sternum and left outline of 
cardiac region are heard short pleuritic rales with inspiration. On an oc- 



156 ST. LUKE'S HOSPITAL REPORTS 

casional deep breath by patient fine crackling rales are heard in bases of 
both axillae, posteriorly and at both bases. 

Abdomen.— Muscles are held rigidly. Liver percusses to free border; edge 
not felt. Spleen not palpable. No pelvic masses or tenderness made out. 

Back.— On upper part of left buttock is a red, excoriated area, 2 x 2% 
Inches, with round, black, central slough. No masses or tenderness found 
In sacro-iliac joint region. 

Extremities (Upper).— There Is considerable rigidity of arms, but no joint 
involvements made out. The left hand is deformed, being flexed at wrist, 
with extension of first three fingers, and flexion of last two fingers. The 
grip Is weak. There is no atrophy of muscles. Reflexes are active. 

Extremities (Lower). — Knees are flexed; extension causes pain. K. J. 
are active. No edema. The left knee is slightly swollen, red, hot and tender. 
No fluid made out. There is evidently a partial foot drop on left side. The 
ankle is slightly red, and causes pain when touched or moved. There is no 
marked response to pressure over either sciatic nerve, but flexion of legs causes 
pain, particularly on left side. 

Eye grounds normal, except for physiological excavation. 

Ears. — Right, acute inflammation on the site of an old purulent otitis. Left, 
scar in inferior portion; serum thick. 

The admission temperature was high, 103°. A leucocytosis of 19,500, with 
a polynuclear count of 85 per cent, and joint inflammation combined with 
a suppurating ear, made a septic process the probable diagnosis, the only 
question being the location of the process. The deformity of the hands and 
partial foot drop, with a history of a limp and deformed hand, made one fairly 
confident of an old infantile lesion in the neighborhood of the right internal 
capsule, and probably not related to the present condition. The following 
day rigidity of the neck developed, and lumbar puncture was performed to 
determine the presence or absence of meningitis. A clear sterile fluid was 
obtained under only slight pressure. Blood cultures proved sterile. The 
leucocytosis grew more intense, 35,000. The systolic murmur at the base 
became louder and harsher, and a soft systolic murmur was heard at the 
apex on July 29th, on which date lumbar puncture was again performed, and 
10 c.c. of clear fluid obtained. 

Early in August she was transferred to the surgical side, and the right 
mastoid explored and the dura inspected, but without result, the autopsy 
showing an acute vegetative endocarditis and old calcareous cerebral lesions, 
which may have been either old solitary tubercles or inspissated masses of 
pus with calcification. 

Autopsy. — August 6 and 7. Body of much emaciated woman of middle 
age. Several large pigmented moles on abdomen. Left leg abducted, and 
pelvis tipped to left in compensation. Left hip enlarged. Two bed sores on 
this surface. Both forearms wasted. Contractures of left hand. Many teeth 
missing, others in bad condition. Right mastoid chiseled out and packed 
with gauze. 

Peritoneum normal, except for old, dense adhesions about the spleen. 

Pleurae obliterated by old adhesions, which are very dense posteriorly. 



MALIGNANT SEPSIS 157 

Lungs. — Left apex voluminous and firm, base collapsed and boggy. On 
section, surface moist and gelatinous. A large amount of edematous fluid can 
be expressed, leaving some granular areas. Base deep red on section, and 
contains edema fluid. Rigbt upper lobe voluminous and firm, lower collapsed 
and boggy. On section, upper presents a moist gray and red surface, quite 
solid, witb yellow clots of thick pus scattered throughout. Further sections 
show cavities up to 2 cm. in diameter, fixed by their fibrous tissue, and filled 
with brownish, turbid fluid. Base congested. Bronchial nodes enlarged and 
caseous. 

Heart. — Pericardium normal. Heart small, atrophied; mitral valve has a 
row of large fibrinous vegetations along line of closure, some projecting 4 mm. 
into lumen. Aortic cusps show smaller vegetations, y 2 mm. in diameter, about 
the corpora arantii and on folds where the cusps join. The heart muscle 
is pale and brownish. 

Spleen. — Small, very soft, and adherent. 

Kidneys. — Normal size; capsule strips readily. Cortex very pale; epithe- 
lium opaque. Markings well preserved and regular. 

Liver. — Normal size. 

Stomach. — Normal. 

Intestines. — Normal. 

Pancreas. — Normal. 

Aorta shows slight atheroma. 

Brain. — Very dense and fibrous ; moderate edema of pia in temporal fossa. 
Cerebellum adherent to dura over lateral posterior portion of left lobe. At 
this point there is a dense calcareous mass, about 2 cm. in diameter, in the 
cerebellar tissue. Cortex normal. 

On section, a cavity is found occupying the position of the head of the 
caudate nucleus, and partially replacing the lenticular nucleus and anterior 
limb of the internal capsule on the right side. It measures 18 x 10 x 10 mm. 
in diameter, and is separated from the lateral ventricle by a delicate wall. 

From the floor of the cavity a papillary calcified mass projects upward 
into the cavity. The cavity is filled with thin, slightly turbid, brownish fluid. 
Scattered about the sulei, beneath the pia, are a number of spherical nodules 
3 cm. in diameter, of about the color and consistence of white matter of lime. 

Anatomical Diagnosis. — Acute endocarditis, septic pneumonia of right upper 
lobe, and broncho-pneumonia of left upper lobe. 

Healed tuberculosis of brain and cerebellum. Section and microscopical 
examination did not prove tuberculosis. 

Bacteria. — Smears from heart valves gave + cocci in pairs and short chains, 
also large, coarse Gram + bacilli and smaller Gram negative bacilli. No 
tubercle found. 

Cultures from lung and heart valves all showed a colon-like bacillus. (Prob- 
able post-mortem contamination.) 

Section apparently through basal ganglion shows thickening of glia 
usual about subependymal vessels. There is also an island of glia tissue in 
the ganglion. 



158 ST. LUKE'S HOSPITAL REPORTS 

The case is mainly of interest in disassociating the old from her 
recent symptoms. How much importance to attach to her chronic 
ear as a site for the portal of infection, whether or no a pus focus 
lay under the old otitis in the silent area of the lesion, was difficult to 
make out in the presence of increasing meningeal symptoms such as 
rigidity of the neck and Kernig's sign, with increasing signs of 
cerebral irritation. 

The site of the active focus was probably in the vegetations on the 
heart valve, with a probable portal of entry from the ear or the oral 
cavity. 



THE DILATATION TEST FOR CHRONIC APPENDICITIS.*! 

W. A. Bastedo, M.D. 

That many persistent digestive disturbances are manifestations of 
a latent or chronic appendicitis has been repeatedly demonstrated by 
the disappearance of the disturbances after the removal of the ap- 
pendix. It is also well known to operators that in some of these cases 
the appendicitis was not recognized for a long time, and that even 
after long observation there were cases in which there was a large ele- 
ment of uncertainty as to whether the appendix was involved or not. 
In other words, the appendicitis was latent, and could not be de- 
tected by the ordinary means of examination. Hence any measure 
by which such a latent appendix involvement can be recognized de- 
serves consideration. "We would, therefore, again call attention to the 
usefulness of dilating the colon with air to determine the presence 
or absence of a latent or chronic appendicitis. Since our first report 
of the test, we have applied it in a large number of abdominal cases, 
and have been able in a number of instances to establish the diagnosis 
of appendicitis when all other methods of examination failed com- 
pletely or left the examiner in a state of reasonable doubt. In ad- 
dition, we have received verbal reports from several surgeons who 
have been employing the test as a routine in their hospital cases. In 
their experience, as well as our own, the test as checked by operation 
has proved reliable, failure being reported in only 4 or 5 cases in 
several hundred. 

To make the test a colon tube is passed 11 or 12 inches into the 
rectum and air injected by means of an atomizer bulb. If, as the 
colon distends, pain and tenderness to finger-point pressure become 
apparent at McBurney's point, there is appendicitis. We have com- 
pared the test in a number of instances with the Rovsing test and 

*Read before the Medical Society of the County of New York, May 23, 
1911. 

J Extracted from the American Journal of the Medical Sciences, July, 1911. 

159 



160 ST. LUKE'S HOSPITAL REPORTS 

find the dilatation test much the more certain; but at times, after 
moderate dilatation with air, the Rovsing method of forcing the air 
back into the cecum may be used with advantage. "We might sound 
a warning that if most of the air is not allowed to escape before with- 
drawal of the tube, colicky pains are likely to ensue. 

The test is not needed in an acute case, and in such would be con- 
traindieated ; neither is it required in an undoubted chronic case. 
But the indication for the test is a suspected chronic or latent appen- 
dicitis, or any persistent digestive or abdominal disturbance, in which 
no cause can be found for the trouble. Ordinarily one may entertain 
doubt about the diagnosis, or at least hesitate about urging operation, 
when tenderness at McBurney's point can be elicited only on very 
deep pressure, or is accompanied by a similar tenderness elsewhere 
in the abdomen. At times, for example, we have thought of appen- 
dicitis because of McBurney's point tenderness, but have found in 
addition puzzling points of tenderness along the transverse colon or 
at a spot on the left side corresponding with McBurney's. In such 
cases, dilatation frequently results in the disappearance of all the 
points of tenderness except that at McBurney 's, which it intensifies. 

Again, in persistent cases of hyperchlorhydria or gastrosuccorrhea 
the test should be performed. For just as in the case of a cholecystitis, 
so a latent appendicitis may have its chief manifestation in stomach 
derangement, even so marked at times as to simulate an ulcer. And 
since it has become our routine practice to dilate the colon in all long- 
standing cases of the kind, we have had the good fortune in a number 
of instances to discover an unsuspected appendix and to see the gastric 
symptoms disappear with the removal of the offending vestige. 

A further application of the test may be to distinguish between 
an inflamed appendix and a right-sided pelvic trouble. Pain and 
tenderness in a right-sided chronic salpingitis or cystic ovary some- 
times result from the colon dilatation, but the tenderness is regu- 
larly less acute, is low down in the abdomen, and extends toward the 
middle line. In three instances we have been able to diagnosticate 
pelvic inflammation in young women in whom appendicitis was sus- 
pected and in whom a vaginal examination was impossible except 
under ether. In each of these the subsequent operation revealed a 
cystic right ovary and a free uninvolved appendix. We have em- 
ployed the test in not a few other gynecological cases, and while in 
some we have been able merely to corroborate the findings of a vaginal 
examination, in others we have demonstrated appendicitis in addition 



DILATATION TEST FOR APPENDICITIS 161 

to the pelvic lesion. In every such case operated upon the finding 
of the dilatation test has been found correct. 
A few typical case reports may be of interest : 

Case 1. — G. L., painter, has had attacks of pain in the abdomen at inter- 
vals for iy 2 years, without nausea or vomiting. Recently such attacks have 
become more numerous, and in the last, he had to lie down for one afternoon; 
he was thought to have painter's colic. He told us that the pain occurred 
mostly just above the umbilicus or high up beneath the right ribs. He had 
no lead line on the gums, no polychromatophilia in the blood. On colon dila- 
tation, the gall-bladder was not made out, and no pain appeared in the he- 
patic region; but in 2 spots there were pain and tenderness, 1 spot just at 
McBurney's point and another just below the navel. A small umbilical 
hernia also made its appearance. The patient was advised to have an oper- 
ation for the hernia and the appendicitis, but as the diagnosis was not con- 
firmed by others he was treated for 3 months for lead poisoning, intestinal 
indigestion, and rheumatism. The attacks, however, increased and were 
more localized in the appendix region, so he returned for operation. The 
dilatation test was again positive, and operation was performed by Dr. H. 
H. M. Lyle. The chronically inflamed appendix was covered by veil-like 
adhesions, which extended to the hernial opening; the gall-bladder contained 
no stones. The appendix and adhesions were removed and the hernia closed. 
The patient has had no more attacks of the old type, and a little recurrence 
of the pain beneath the right ribs disappeared quickly under treatment for 
hyperchlorhydria. 

Case 2.— D., a physician, in 2 years had 5 attacks of severe pain in the 
abdomen, with prostration and vomiting. The pain was always diffuse, never 
localized, and lasted about one day ; the temperature never rose above 99° F., 
and the pulse was normal or slow. Physicians had suggested appendicitis, 
but no positive diagnosis was made. Two days after the last attack, which 
was so severe that morphine had been administered, the patient walked to my 
office apparently well. Slight tenderness to finger-point pressure at Mc- 
Burney's point could be elicited only on very deep pressure, but on dilating 
the colon an acute pain appeared in the appendix region, and tenderness 
over an area as large as a silver dollar and centering over McBurney's point. 
Four days later, Dr. J. A. Blake operated and found a chronically inflamed 
appendix with a constriction close to the cecum, and adhesions extending 
upward over the cecum. The patient has had no attack since the operation 
(about 2 years). 

Case 3.— Mrs. R., 12 years ago, had an attack of pain in the abdomen, 
with vomiting, and was in bed 1 day. A surgeon saw her in the attack, and 
said it was not appendicitis. During the entire 12 years since then she has 
taken a laxative pill every night and has had no further severe pain, but for 
the last 6 months has been losing appetite and becoming more costive, and 
has been irritable and in low spirits. A month ago had a little abdominal 
pain on the right side for 1 day, but not enough to require treatment. A 
test breakfast showed free hydrochloric, 48; total acidity, 70. No organic 



162 ST. LUKE'S HOSPITAL REPORTS 

acid. On dilatation of the colon, pain at McBurney's point with sharply 
localized tenderness became manifest. It was our belief that hyperchlor- 
hydria treatment would be futile in the presence of a chronic appendicitis, 
so operation was advised, and Dr. L. W. Hotchkiss removed a retrocecal 
swollen appendix with 3 marked constrictions and surrounded by adhesions. 
Since the operation, 8 months ago, the patient has had unusually good di- 
gestive and bowel functions, and has been in excellent general health and 
spirits. 

Case 4.— Miss H., aged 24 years, a rather under-developed young woman, 
with a mitral stenosis, has had in the last year several attacks of cramp- 
like pain in the right iliac region. Two or 3 times this pain came at the 
menstrual period, but it occurred also at other times. Vaginal examination 
was not feasible, so the colon was dilated. At once there was a dull pain 
over the whole lower right segment of the abdomen, extending from Mc- 
Burney's point to Poupart's ligament and to the midline. Tenderness was 
slight, and was most pronounced about half way between McBurney's point 
and the symphysis pubis. Operation by Dr. H. T. Goodwin showed a right 
ovarian cyst and a normal appendix. 

Case 5.— Miss G., aged 27 years, has had pain in the right side low down 
for a year or more. It has never been very acute, never caused vomiting, 
and was most pronounced after the patient had been a long time on her feet. 
There has been a rather abundant vaginal discharge. Examination per 
vaginam reveals a tender boggy mass in the right fornix, and much tender- 
ness when the uterus is moved. Out of curiosity, the colon was dilated, and 
to our surprise an acute pain appeared in the appendix region, and tender- 
ness localized at McBurney's point. Operation by Dr. Frank Markoe showed 
right salpingitis with tube, ovary, and chronically inflamed appendix bound 
together in a mass of adhesions. 

Case 6.— D. S., has never had any acute attack of appendicitis, but has 
had some pain in the appendix region when his bowels seemed full of gas. 
Dilatation was positive for appendicitis. Some time later, in Chicago, he 
had an acute attack which was diagnosticated appendicitis, and though 
prostrated, and with fever, he took train immediately for New York. Dr. 
H. H. M. Lyle operated and found a retrocecal abscess with a sloughed off 
appendix. 

These eases illustrate the positive findings of the dilatation test. 
In the use of the test during the last four years we have had no case 
in which the test was positive and the operation findings negative. 
But in two out of all of our cases the negative finding of the test, after 
a supposed appendix attack, was followed within six months by a 
typical attack of appendicitis, and the test was, therefore, presumably 
at fault. Several times in the early days of the test, surgeons operated 
for a suspected appendicitis, though the test was negative, and in every 
such case the appendix was found normal. "We have had a verbal 



DILATATION TEST FOR APPENDICITIS 163 

report from one surgeon who has used the test extensively, of two eases 
which gave positive test but negative findings at operation. With 
very few exceptions, therefore, the test has proved accurate, and it 
may well serve as a diagnostic guide in the three classes of cases men- 
tioned, viz., suspected chronic appendicitis, persistent gastro-intestinal 
or abdominal disturbance with unknown cause, and appendicitis versus 
ovarian or tubal inflammation. 



THE VACCINE TREATMENT OF TYPHOID FEVER. 
Austin W. Hollis, M.D., and Norman E. Ditman, M.D. 

During the past few years the undoubted success of the preventive 
inoculation against typhoid fever has been proved. Among the 60,000 
men in the United States army who have been inoculated against 
typhoid fever during the past three years, there have been no deaths 
from typhoid, and but 12 cases of fever have occurred. 

These figures furnish evidence beyond dispute that the use of 
typhoid vaccine in the amounts now employed, at least in men in 
health, produces very real immunity. 

The practical question of interest which now remains to be solved 
is, how late in the course of an attack of typhoid fever is it advisable 
to attempt to aid or increase the immunity which the sick subject is 
attempting to establish, and what benefits, if any, are to be gained 
for the attack of illness already in progress. 

It has been difficult to predict, on theoretical grounds, what the 
effect would be of adding bacterial products to a case of illness ap- 
parently already overburdened with products of a similar nature; 
yet, experience is beginning to show that while an attack of typhoid 
fever of average intensity may seriously impair the activities of the 
person attacked — producing the picture of severe illness — yet their 
powers of bacterial resistance through increased immunity may still 
be greatly augmented. 

During the past few years one fact of undoubted value has been 
clearly proved — rendering the path clear and safe for future work 
along this line. That is, that the administration of typhoid vaccine 
to a case of typhoid — unless that case be moribund from an over- 
powering toxaemia — produces no harm or undesirable symptoms of 
any kind. 

During the past 3 years, on the service of Dr. Austin "W. Hollis, 
typhoid vaccine has been administered uniformly to cases of typhoid 

164 



VACCINE TREATMENT OF TYPHOID FEVER 165 

fever. The doses have consisted of 1 c.c. of Parke, Davis & Co. typhoid 
vaccine every other day — each c.c. containing 50,000,000 dead bacilli. 

In the 1909 series, 11 cases were thus treated. No deaths occurred. 

In comparison with 21 unvaccinated cases, there were no deaths 
to 4, 30 per cent of relapses to 10 per cent, 34.3 days duration of 
fever to 36.7 and an equal number of hemorrhages. In the 1910 
series of 40 vaccinated cases, the mortality was 5 per cent, relapses 
10 per cent, no hemorrhages and no perforations, with an average 
fever duration of 30 days. 

In the 1911 series of 35 cases, the mortality was 8.5 per cent, there 
were 2.8 per cent of relapses, 5.7 per cent of hemorrhages, no per- 
forations and an average fever duration of 28 days in the non-fatal 
cases. 

During this same year, in other services of St. Luke's Hospital, in 
35 cases where typhoid vaccine was not administered, the mortality 
was 14.3 per cent, there were 23 per cent of relapses, 2.9 per cent 
hemorrhages, 2.9 per cent of perforations and an average fever dura- 
tion of 33.2 days in the non-fatal cases. 

Summarizing the available statistics for the 3 years, the following 
results are obtained: 

Vaccinated cases Unvaccinated cases 

Number Per cent Number Per cent 

Cases 86 .... 56 

Deaths 5 5.8 9 16. 

Relapses 9 10.4 10 17.8 

Hemorrhages 2 2.3 1 1.8 

Perforations 1 1.8 

Average duration of fever 30.3 days 33.7 days 

Still better results are reported in recent literature as follows: 
In 214 vaccinated cases collected by Callison, the mortality was 
5.6 per cent, with relapses in 5.1 per cent of the cases. 

To realize how vaccination influences the course of typhoid fever, it 
is of interest to compare these results with those of a very large series 
of typhoid fever cases collected by Osier, in which the standard 
methods of treatment were employed. They are as follows: 

Per cent 

Mortality 11.2 

Relapses ]1.4 

Hemorrhages 7.0 

Perforations 5.7 

Average duration of fever 29.4 days 



166 ST. LUKE'S HOSPITAL REPORTS 

It is therefore apparent that, as far as the present total of statis- 
tics goes, there is an appreciable difference in favor of the vaccinated 
cases. The proper dosage and frequency of administration is yet to 
be determined. 

In some of the recent cases of the St. Luke's series some doses of 
more than 50,000,000 were given, and in a small number, on alternate 
days, small doses of Schaeffer's vaccine was given hypodermatically. 

In the St. Luke's non-vaccinated cases, tub baths were given, and 
a diet ranging from 2,000 to 3,200 calories; while in the vaccinated 
cases the diet did not exceed 1,500 calories and the tub bath was dis- 
pensed with — its place being taken by sponges. 

In any series of hospital cases which are unselected, a number of 
cases are found which enter the hospital late, in a more or less mori- 
bund or hopeless condition. 

Among the fatal cases in the vaccinated series these are frequent. 
Thus, in the 1910 series, both fatal cases entered the hospital in the 
fourth week and died 8 and 4 days after admission — the latter from 
pneumonia, 6 weeks after child-birth. 

In the 1911 series, of the 3 fatal cases receiving vaccines, one en- 
tered the hospital on the 16th day, in an extremely toxic condition, 
and died on the 20th day — having received but 1 dose of vaccine. 
One case was admitted on the 16th day, in an extremely toxic con- 
dition, and died from a hemorrhage on the 25th day. The third 
case was admitted on the 28th day, and died from a hemorrhage on 
the 34th day. 

Therefore, it may be said that while vaccination has little influence 
on late cases, yet, on the other hand, if vaccination is begun early, 
good or even brilliant results may be expected. For, among the large 
number of St. Luke's cases during 3 years of observation, in which 
vaccination was begun before the 16th day, there were no deaths. On 
the other hand, it must be remembered that had all the cases of the 
unvaccinated series entered the hospital before the 16th day, the per- 
centage of mortality in that series would undoubtedly have been much 
lower. 

Observers in general who have seen vaccinated and unvaccinated 
cases, seem to agree that in the vaccinated cases the ' ' typhoid state is 
rare, the early toxic symptoms of the disease quickly disappear and 
the disease in general is better borne. ' ' 

Major Russell, of the United States army, has shown that in normal 
subjects the typhoid immunity reaction does not begin until about 



VACCINE TREATMENT OF TYPHOID FEVER 167 

7 days after the vaccination. Whether the same holds true for fever 
cases might be very difficult to determine. A fall in temperature 
has often been noted within 48 hours after vaccination ; but it is sel- 
dom that any pronounced improvement begins until after the sixth 
day from the first vaccination. 

If vaccine has been used up to the 25th day of the disease, it is 
believed that its further use is not likely to be of benefit; while a 
long continued fever of the septic type is more likely to be benefited 
by some other form of treatment, and we have undoubtedly seen these 
cases clear up quickly under combined vaccine. 

From the experience of the past 3 years in St. Luke's Hospital, it 
is believed that it may be well to give an initial dose of 50,000,000 
as early in the disease as possible, repeated every other day until the 
tendency of the fever is downward, when the dose may be doubled 
at every succeeding injection, provided the fever is still declining. 
Injections should be continued until there is no danger of a relapse — 
avoiding, however, a dosage which might be considered excessive in 
amount. 

Whether this maximum dose will prove to be 500 million or 2,000 
million, statistics of the next few years will prove. 



A CASE OF PAGET 'S DISEASE.* 
Karl M. Vogel, M.D. 

In spite of the fact that ostitis deformans, or Paget 's disease, as 
it is generally called, is not a remarkably rare condition, at least in 
its minor grades, the diagnosis is not very often made, and it is only 
comparatively recently that cases have begun to be reported with any 
degree of frequency. 

Paget, in 1877, first isolated this type of deformity from the gen- 
eral hodge-podge of chronic bone diseases, and in the Medico-Chirur- 
gical Transactions for that year outlined a clinical picture to which 
subsequent observers have made few additions of moment. As he 
described it, the disease is one beginning in middle life or later, pro- 
gressing very slowly during many years, and causing no disturbances 
other than those due to mechanical changes in the diseased bones. 
Those most often involved are the long bones of the lower extremities, 
the cranium, spine, and clavicles. The bones enlarge and soften, and 
owing to the pressure of the body weight become curved and mis- 
shapen, so that finally with the shortening thus produced, as well as 
through curvature of the spine, the stature steadily decreases. The 
pain is variable in severity and is most common in the earlier stages 
of the disease, though it may persist indefinitely. 

In a later communication, Paget 1 summed up the most prominent 
symptoms, as follows: 

"It usually affects many bones, most frequently the long bones of the lower 
extremities, the clavicles, and the vault of the skull. The affected bones 
become large and heavy, but with such weakening of their structure that those 
which have to carry weight or to bear much muscular traction become unnatu- 
rally curved and misshapen. The disease is very slowly progressive, and is 
felt only in pain, like that of rheumatism or neuralgia, in the affected limbs, 
and in increased heat at the tibiae. But neither the pain nor the heat is 

*Read at a meeting of the Section on Medicine of the New York Academy 
of Medicine, May 16, 1911, and reprinted from the Medical Record July 
29, 1911. 

a Paget: Medico-Chirurgical Transactions, London, vol. lxv, 1882. 

168 



A CASE OF PAGET'S DISEASE 169 

constant, nor do they continue during the whole progress of the disease ; and 
pain has not been observed in the head even in the cases in which the skull 
was greatly thickened. There is not any clear evidence of general disturbance 
of health. In all the cases traced to the end of life, death has ensued through 
some coincident, not evidently associating, disease, which has been aggravated 
by the condition of the bones only in so far as they may have diminished the 
range of breathing and the general muscular activity. 

"In all of the cases I have seen, the general appearance, postures, and 
the movements of the patients, have been so alike that these alone might often 
suffice for the diagnosis of the disease. The most characteristic are the loss 
of height, indicated by the low position of the hands when the arms are hang- 
ing down; the low stooping, with very round shoulders and the head far 
forward, and with the chin raised as if to clear the upper edge of the sternum ; 
the chest sunken toward the pelvis, the abdomen pendulous ; the curved lower 
limbs, held apart, and usually with one advanced in front of the other, and 
both with knees slightly bent; the ankles overhung by the legs, and the toes 
turned out. The enlarged cranium, square-looking or bossed, may add dis- 
tinctiveness to these characters, and they are completed in the slow and 
awkward gait of the patients and in the shallow costal breathing, compensated 
by wide movements of the diaphragm and abdominal wall, and in deep breath- 
ing by the uplifted shoulders." 

In regard to the order of involvement of the bones it may be stated 
that Packard, Steele, and Kirkbride, 2 from an analysis of a very large 
number of cases, found that this was as follows: Skull, tibiae, femur, 
spine, pelvis, clavicles, ribs, radii, ulnae. The fibulae seem to be but 
rarely affected, but Maier has reported a case in which the disease 
began in one fibula and in the small bones of the foot. 

Paget correctly interpreted the condition as being a chronic inflam- 
matory process, and accordingly suggested that it be known as ostitis 
deformans. Recklinghausen termed it ostitis fibrosa. The changes in 
the bone structure may be regarded as the result of two opposing 
processes, resorption and hyperplasia ; that is, a rarefying and a con- 
densing ostitis. Both the spongy and the compact portions of the 
bone are involved, the destruction of the lamellae being accompanied 
by replacement with fatty, gelatinous, or fibrous tissue which fre- 
quently shows localized areas of softening and liquefaction, so that 
cyst-like cavities filled with fluid develop. In addition, calcification oc- 
curs and irregular deposits of new bone are formed throughout the 
entire substance of the bone, resulting in an increase in its size and 
density. The marrow becomes converted into a more or less fibrous 
or gelatinous mass containing giant cells, fat cells, and leucocytes. 

'Packard, Steele and Kirkbride : Am. Jour. Med. Sciences, vol. cxxli, 190L 



170 ST. LUKE'S HOSPITAL REPORTS 

Various authors differ somewhat in their views as to whether the 
process begins subperiosteally or in the marrow, and as to the precise 
sequence of events; but the essential features are the combination of 
softening and curvature of the bone, together with an increase in size 
and density, so that the picture presented by the individual bones 
may be very variable, and the processes of halisteresis, absorption, 
and calcification of newly formed osteoid tissue may be going on 
simultaneously. The surface of the bone may be smooth or rough; 
the cortex compact or spongy ; the cancellous portion dense or porous ; 
the central canal almost obliterated or widely dilated. 

In regard to the etiology little more is known than in Paget 's time. 
General arteriosclerosis is constantly present and it has been sug- 
gested that the bone lesions are due to sclerosis of the nutrient ves- 
sels of the bone. French observers have considered that the disease 
is a manifestation of hereditary syphilis or a paraluetic condition, and 
have reported improvement as the result of mixed treatment. Nerve 
lesions and gout have also been mentioned as possible etiological fac- 
tors, but without very satisfactory confirmatory evidence. Joint 
changes occur, but are not very common, although Richard and Zieg- 
ler hold that the disease is allied to arthritis deformans. Prince 3 , 
who regarded the disease as a trophic disorder, has laid stress on the 
possibility of there being changes in the central nervous system, 
but as yet nothing significant has been discovered. An interesting 
fact noted by Paget himself, as well as by later writers, is the com- 
parative frequency with which new growths of various sorts, includ- 
ing osteosarcoma, occur in the subjects of the disease. A possible 
hereditary predisposition has been alleged, since in a number of in- 
stances members of the same family have been victims of the disorder. 
Bockenheimer 4 holds that a congenital anomaly of bone metabolism 
is an underlying factor. 

The direct prognosis, as far as life is concerned, is good, though a 
subject of the disease, through arteriosclerosis and through local con- 
ditions dependent upon the deformity, may be more susceptible to 
the disorders of old age than an individual not so affected. 

The treatment is largely symptomatic and consists chiefly in con- 
trolling the pain, when present, though some writers have reported 
encouraging results from the administration of thyroid extract. At- 
tempts at surgical correction of the deformity of the long bones are 

'Prince: Am. Jour. Med. Sciences, vol. cxxiv, 1902. 
'Bockenheimer : Arch. f. klinische Chirurgie, vol. lxxxv, 1908. 



A CASE OF PAGET'S DISEASE 171 

contraindicated. In one case of Sonnenberg V in which an osteotomy 
was performed there was no evidence of callus formation 13 months 
later. 

The question of diagnosis is a more complex one, for while it is 
not very difficult to recognize the disease when well advanced so that 
the curvature and enlargement of the bones are apparent, the head is 
misshapen, the stature shortened, and the patient presents the typical 
ape-like aspect, in its earlier stages or in mild cases, when, perhaps, 
only a single bone is involved and the patient complains solely of 
fleeting pains, it is no doubt often mistaken for sciatica, rheumatism, 
neuralgia, arteriosclerosis, etc., and many cases are accordingly over- 
looked. Among the bone diseases that might be confounded with it 
are osteomalacia, spondylitis deformans, hypertrophic pulmonary 
osteoarthropathy, and possibly acromegaly, but these all differ in more 
or less striking particulars from Paget 's disease when well developed. 
One form of disease, however, requires especial mention in this con- 
nection, and that is the diffuse enlargement of the skull described by 
Malpighi in 1697, and to which Virchow gave the name of leontiasis 
ossea, because, as he said, in looking at representations of such skulls 
one is reminded of the appearance of the plaster cast of a case of 
leprous leontiasis. Later authors, however, prefer the designation 
"diffuse cranial hyperostosis." Most of the writers on bone disease 
have apparently taken it for granted that this condition and Paget 's 
disease are independent affections, and have given various differential 
points by the aid of which the two might be distinguished. These re- 
late chiefly to the age at which the disease first appears, and to minor 
distinctions in regard to the nature of the bony changes, extent of 
involvement of the fissures and foramina of the skull, the occurrence 
of nervous disturbances, etc. Recent authors, however, notably Bock- 
enheimer, Prince, and Fitz R , have suggested that the two conditions 
are certainly closely allied and probably identical. But the question 
has remained a somewhat open one because until rather recently in- 
formation as to the leontiasis skulls was largely derived from more 
or less ancient museum specimens generally provided only with in- 
adequate clinical histories, so that the possible coexistence of slight 
changes in other bones could not be altogether excluded. Latterly 
more definite data have been available, for the microscopic examina- 
tion of tissue removed at operation on leontiasis patients for the pur- 

B Glaessner: Wien. klin. Wochenschrift, 1908, p. 1327. 
6 Fitz : Am. Jour. Med. Sciences, vol. cxxiv. 1902. 



172 ST. LUKE'S HOSPITAL REPORTS 

pose of relieving pressure symptoms has revealed changes precisely 
similar to those found in the long bones in Paget 's disease. An im- 
portant contribution to the matter was made not long ago by Max 
Koch 7 , who presented before the German Pathological Society the 
skull of a carefully observed patient clinically suffering from leon- 
tiasis, which showed on section the usual appearances of Paget 's dis- 
ease ; so that it now seems rational to regard leontiasis ossea as a local 
occurrence of lesions which when more widely distributed produce 
the picture of Paget 's disease. 

The history of Koch 's case is briefly as follows : 

The patient was a woman of 65 years, who was observed during a year's 
stay in the hospital. The symptoms began twenty years previously, when 
she noticed an increase in the size of the head and at the same time tinnitus, 
vertigo, headache, and impairment of vision developed. Her hearing became 
impaired only a few months before her entry into the hospital. The circum- 
ference of the head was 72 cm., or about 29 inches. There was pronounced 
enlargement of the temporal arteries, and the ears stood out prominently 
from the head. Ophthalmoscopic examination was negative, and the visual 
fields were not restricted. Myopia of — 5 D. S. There were hyperostoses of 
both external auditory meatuses and hypertrophy of the inferior turbinates and 
nasal septum. The hard palate was so much thickened that the laryngoscope 
could not be used. The lower jaw was not thickened. The Wassermann 
reaction was negative. During her stay in the hospital she suffered chiefly 
from headache, pain in the legs, vertigo, and general weakness. Five days 
before death she suffered from an apoplectiform attack, with unconsciousness, 
but no paralysis. Death appeared to be due to a general loss of strength. At 
the autopsy it was found that there was a synostosis between the axis and 
third cervical vertebra. There was a moderate kyphosis in the thoracic region, 
£>ut no abnormality of the other bones. The blood-vessels were markedly 
-sclerotic. On sawing through the skull, it was found that the differences in 
structure between the external and internal tables and the diploe had disap- 
peared, and the bone was very friable. The thickness of the frontal bone was 
from 4 to 6 cm., that of the temporal from 3 to 3.5 cm., and of the occiput, 
l2.5 to 3 cm. There was an abscess cavity in the situation of the frontal 
sinus on one side, but on the other the sinus had been entirely obliterated. 
The cut surface was made up of spongy bone, with grayish-red, dense, fibrous 
tissue, with here and there areas of gelatinous marrow, or cavities filled 
with fluid. All the foramina and fissures of the base were much narrowed, 
except the foramen ovale. The meninges were normal, but the brain appeared 
flattened and diminished in size through pressure. The pituitary body was 
flattened, but in section showed no abnormalities. 

Microscopical examination of the bones showed the changes described by 
Paget as ostitis deformans, and by von Recklinghausen 8 as ostitis fibrosa, 

'Koch: "Verhandlungen der Deutsch. patholog. Gesellsch.," 1909. 
•v. Recklinghausen : "Virchow's Festschrift," 1891. 





Fig. 1. — Photograph of patient at the 
age of 34 years. 



Fig. 2. — Photograph of patient at the age 
of 44 years. 











^^F^ *^ 






Wi^i 






^v> 






i 






* 




W.. L 


• 


1 V 




Fig. 3. — Present appearance of the patient. 



Fig. 4. — Present appearance of the patient. 

Note especially the appearance of 

the ear. 



A CASE OF PAGET'S DISEASE 173 

Koch accordingly believes that this case definitely proves the identity of leon- 
tiasis ossea with Paget's disease. 

The history of the case forming the subject of the present report 
is as follows: 

The patient was a woman, aged 68, born in England, a seamstress. Ad- 
mitted to St Luke's Hospital on December 5, 1910, to the service of Dr. 
Janeway. 

Family history negative, except that one sister is said to have died of 
cardiac trouble, and various members of the family have had "weak hearts." 
There is no history of bone changes similar to those of the patient, and all 
other members of the family are well formed, active individuals. 

Previous history : When about two years old her head was caught between 
a clothes mangle and a door. She says that her head has always been large 
and ill-formed, and believes that this is due to this accident. She has no 
remembrance of the diseases of childhood. At eleven years of age, after a 
fright, she had "fits," during which she would become unconscious, but she 
does not remember falling or hurting herself during these attacks. A short 
time later she awoke one morning and found that her right side was paralyzed. 
For a time she had to be fed, and helped in walking, but the paralysis gradu- 
ally disappeared, and she had no more of the fits after her sixteenth year. 
About twenty-five years ago she had several abscesses in the left external audi- 
tory canal, and at the same time that side of her head became swollen and 
bumpy. She believes that the present swelling above her ear is due to this 
cause. 

Present illness : Dates back about fifteen years. Previous to this time she 
had always been a good walker, but she then began to notice a feeling of 
weakness in her legs, which gradually increased, until about ten years ago, 
when she was obliged to give up her work, as it took her so long to do any- 
thing, and she could not think quickly. If she wished to do anything across 
the room, it would take her half an hour in thinking about it and in getting 
up and crossing the room. She had some dull pains in her legs at this time, 
and also began to grow deaf. During the last five years the pains in her 
legs have become more severe. Her gait has become very slow and shuffling, 
and she cannot lift her feet. Two years ago she noticed that the legs were 
becoming crooked. She has suffered from headache most of her life, and lately 
her head has felt heavy, so that it drops forward and it is hard for her to 
lift it She is afraid to lift her head too high in looking at things, for fear 
she will fall over backward. She believes that she has become two inches 
shorter during the past five years. She is of a hysterical nature, and has 
always cried easily, but she has found that lately she cannot shed a tear, 
and has also found that the bridge of her nose has grown too large for her 
glasses. For four or five years her legs have been more or less swollen, and 
recently her arms also have become edematous. For about a year she has 
been short of breath, and the veins in her neck and on her forehead have 
become prominent 



174 ST. LUKE'S HOSPITAL REPORTS 

The patient is depressed, realizing fully her slow mental processes and 
her inability to move or act quickly. 

Chief complaints : Shortness of breath and swelling of arms and legs. 

Physical Examination. — General condition: Patient is a rather poorly 
nourished woman, of small frame, past middle age, showing moderate dyspnea, 
but only slight cyanosis. Her appearance is very striking, on account of the 
marked disproportion between the size of the head and that of the body. The 
head is very markedly enlarged, especially in the upper part; it is rather 
square in shape, with pronounced bony protuberances above each ear. Cir- 
cumference about the forehead is 65 cm., or 26 inches. In the temporal 
region and in the neck are numerous markedly distended pulsating veins. The 
skin of the face appears rather pale and pasty, with numerous brownish pig- 
mented areas. Eyes: Pupils equal, and react to light and accommodation. 
Tongue clean. Throat normal. Upper teeth artificial ; lower in fair condi- 
tion. Chest poorly developed; slight protuberance of upper part of sternum. 
Heart: Rather diffuse pulsation over the lower precordium. The apex im- 
pulse is fairly well marked in the fifth space, four inches to the left of the 
median line. The right border is one inch from the mid-line ; the ieft border 
merges with the dulness of the left chest. At the apex there is a loud, blowing, 
systolic murmur, transmitted to the axilla, and heard over the entire lower 
left chest. The second sounds are not accentuated; the action is rapid and 
irregular. The pulse is rapid, irregular, of poor force and moderate tension. 
The vessel wall is thickened. Lungs: Clear anteriorly; posteriorly, there 
is dulness, beginning just above the angle of the scapula on both sides, and 
becoming flat on approaching the base. Over this area there is diminished 
breathing, becoming absent at the base, where numerous subcrepitant rales 
are heard. The abdomen is somewhat distended. The liver percusses three 
inches below the free border, where its edge can be felt distinctly. It is 
markedly tender, and pulsates. Extremities : Both legs are markedly edema- 
tous, and show moderate curving of the tibiae. 

The patient's height at present is 4 feet 10% inches, whereas she says that 
previously it was 5 feet V/ 2 inches, a shortening of a little over 2y 2 inches. 
She is very deaf, but examination of the ears shows no occlusion or deformity 
of the external meatus. The drums show several patches of fibrous thickening. 

In conclusion, it may be said that a survey of the literature seems 
to support the contention that the separation of diffuse cranial hyper- 
ostosis as an independent disease is not justified and that it is to be 
regarded as a manifestation of the same process which is responsible 
for the symptom complex of Paget 's disease. Further evidence in 
favor of this view is furnished by a case recently reported by Bart- 
lett, 9 in which, as in that described by Koch, during life there was no 
sign of the involvement of any bones except those of the skull. At 
the autopsy, however, examination of the femur showed beginning 
foci of disease. 

"Bartlett : Yale Medical Journal, 1909, p. 367. 




Fig. 5. — Radiograph of the pelvis and femur. 




Fig. 6. — Radiograph of the tibiae. 



THE PURIN CONTENT OF FOODSTUFFS.* 
Karl M. Vogel, M.D. 

The importance of considering the purin content of the diet in the 
diagnosis and treatment of certain metabolic disorders has recently 
been emphasized by numerous writers, for example, by Bessau and 
Schmid, 1 and by Brugsch and Hesse. 3 

The following determinations of the purin content of some of the 
commoner foodstuffs were begun in the fall of 1908, in the II Medical 
Clinic in Munich, at the instance of Prof. Fr. Miiller, and were con- 
tinued in the laboratories of the College of Physicians and Surgeons 
and of St. Luke's Hospital. In the meanwhile, the publication of 
Bessau and Schmid 'a table made it seem unnecessary to continue in 
this direction, but since then Hesse has reported the results of some 
analyses made by him. His figures in general are higher than those 
of Bessau and Schmid, and as mine correspond more closely with the 
latter, it appears of some interest to record them also. 

Hesse, in publishing his figures, calculated the presumptive amount 
of purin bases corresponding to the nitrogen values found. In order to 
make his results comparable to those of other authors who have fol- 
lowed the practice of giving the nitrogen content of the purin precipi- 
tates, I have calculated the nitrogen equivalent of his values, employ- 
ing the customary factor 2.65. One column of the table, however, 
contains his original figures. In the first four analyses of meat and 
organs I used the method of Burian and Hall ; 8 the other determina- 
tions were made by means of the copper-bisulfite method. 4 Of the 
meats, 100 to 250 grams were taken, and of the other articles 250 to 
500 grams. 

♦Translated from the Munchener medizinische Wochenschrift, No. 46, 1911. 
x Bessau und Schmid. Therap. Monat, No. 3, 1910. 
'Brugsch und Hesse. Med. Klinik, No. 16, 1910. 
8 Burian und Hall. Ztsehr. f. physiol. Chem., xxxviii, 336. 
4 Kruger und Schittenhelm. Ztsehr. f. physiol. Chem., xlv, 15. 

175 



176 



ST. LUKE'S HOSPITAL REPORTS 



Beef: Sirloin. 



Liver 

Sweetbread (thymus) 
Spleen 

Codfish 

Wheat flour 

Rye flour 

Pea flour 

Arrowroot 

White bread. 



Rye bread. . . 

Hominy 

Oatmeal 

Rice 

Potato 

Spinach 

Tomato 

Milk 

Swiss cheese. 



c 


■Percentage of purin N- 


* 


%of 




Bessau 






purins 


Walker 


and 








Hall 


Schmid 


Vogel 


Hesse 


Hesse 


0.0522 


0.037 


0.059* 


0.0666 
0.0720 


0.175 
0.189 


0.1101 


0.093 


0.099 


0.142 


0.372 


0.4025 


0.330 


0.398 
0.196 


0.498 


1.308 


0.0233 


0.038 


0.040* 


0.0499 


0.131 







0.001 


0.0441 


0.116 






0.002 


0.0365 


0.096 


0.0156 




0.016 
0.001 


0.0411 


0.108 






trace 


0.008 
0.005* 
0.014 
0.004* 






0.0211 





0.030 












0.0004* 






0.0007 


0.002 

0.024 




0.001* 

0.022* 

0* 


0.0072 


0.019 


0.0002 






0.0002 
0.0004 


0.0038 


0.010 













trace 



♦Refers to analyses made on American material. 



ACUTE BICHLORIDE OF MERCURY POISONING— A REPORT 
OF TWO CASES WITH RECOVERY. 

Lepferts Hutton, M.D. 

The following two cases are reported on account of the apparently 
prevailing custom of keeping bichloride of mercury "Blue Tablets" 
near the fountain syringe to prevent conception. Instead of using 
a bichloride douche, the tablet (7y 2 grains) was inserted into the 
vagina. In looking over the literature on this subject, one is im- 
pressed with the small number of cases of acute poisoning resulting 
from this practice. 

In Germany a law was passed in 1897, making all cases of acute 
bichloride of mercury poisoning reportable. During the next 9 years, 
101 cases of mercury poisoning, from the tablet form, were reported, 
and no record of any case of poisoning from the insertion of the tablet 
into the vagina. The official report for the past 5 years has not yet 
been published, but probably the result will be the same as in the 
preceding 9 years. The sale of mercury in any form is prohibited, 
except on a physician's order. 

In England and her colonies the writer was unable to find any 
case of poisoning by this method. While in America, where any one 
is able to buy the "Blue Tablets," 7 cases have been reported in the 
past 10 years. To this collection of 7 cases the author wishes to add 
2 more, as follows : 

Patient.— Mrs. B.; 38 years old; born in the United States; occupation, 
housework. Entered St. Luke's Hospital as a private patient of Dr. Henry 
S. Patterson, on November 21, 1911, giving the following history: 

On morning of admission, at about 2 A. M., patient inserted a 7%-grain 
tablet of bichloride of mercury in her vagina to avoid conception. Soon 
after she complained of intense burning sensation in that region. Later, the 
patient attempted to douche herself, without much success. She then began 
to realize the gravity of the situation and came to the hospital. 

On entrance, she complained less of the pain in the vagina than of pe- 
culiar paresthesia and cramp-like sensations in the hands and feet. She was 

177 



178 ST. LUKE'S HOSPITAL REPORTS 

not salivated. There were no urinary or intestinal symptoms. Physical ex- 
amination was negative, except for a good deal of redness of the vulva, with 
some whitish slough and a sero-sanguinous discharge from the vagina. 

Vaginal examination, with a bivalve speculum, showed the mucous mem- 
brane to be covered with a whitish slough— cervix very red. 

Treatment and Subsequent Course.— The treatment consisted of force 
fluids, alkaline douche 3 times a day, and a colon irrigation 116° twice a day. 

Blood.— W. B. B. 16,000. Poly. 73.5. Lymph 26.5. Hgb. 90 per cent. Her 
urinary excretion ranged from 64 to 144 ounces a day, while her fluid intake 
varied from 112 to 196 ounces. 

Urine Examination.— Alkaline, sp. gr. 1006-1008, very faint trace of al- 
bumen, no sugar, a very few hyaline casts. 

Stools.— No blood; no increase in number. 

Mouth. — No ulcerated areas ; no salivation. 

The vagina, under the alkaline douches, cleared up very rapidly. She was 
discharged cured, 7 days after onset. 

Mrs. P., age 33, born in Italy, occupation factory hand, entered Dr. S. W. 
Lambert's service at St. Luke's Hospital, on December 8, 1910, with the 
following history: 

Chief Complaint.— Pain in lower abdomen and a sore mouth. 

Present Illness. — Three days ago was seized with sudden pain in lower 
portion of abdomen. This pain was sharp, non-radiating, worse in daytime, 
when at work in the shop. Vomited twice with onset. No chills, fever nor 
cough. Mouth has been sore for the past 3 days, with increased salivation. 
Teeth not loosened. Some difficulty in eating — no treatment during pres- 
ent illness. 

Past history was negative. Menstruated 2 weeks previously ; some leu- 
corrhcea. 

Physical Examination. — Breath fetid, foul-smelling. Lips dry and cracked. 
Sordes on teeth and gums. Tongue badly coated — moderate salivation. No 
evidence of any ulceration in mouth. 

Heart normal. Lungs clear. Abdomen — no masses, no tenderness. Liver, 
spleen, kidneys apparently normal. ♦ 

Vagina.— Yellow and dark brown sloughs on inner side of each labium 
majus. Also yellow and white sloughs on both sides of the vaginal canal. 
The cervix is swollen red, except the places which are covered by slough 
whitish in appearance. A bimanual examination was not made. 

Treatment consisted of bicarbonate of soda throat irrigation. Temper- 
ation of 120° every 3 hours. Alkaline vaginal douche. Colon irrigation of 
hot saline. 

On cross-examination, patient confessed to having placed two bichloride of 
mercury tablets in her vagina 3 days previous to admission and had not 
taken any treatment previous to coming to hospital. 

Subsequent History.— Her vaginal and cervical condition slowly healed. 
Her urinary excretion ranged from 18-30 ounces a day, which, on repeated 
examination, showed a high sp. gr. 1030. No albumen. No blood. No 
sugar. No casts. 



BICHLORIDE OF MERCURY POISONING 179 

Three days after admission patient developed an ulcerative stomatitis, 
which slowly healed. 

On December 23d, 2 weeks after admission, the patient demanded her 
discharge from the hospital. At this time she had some pyorrhoea along 
the gums, otherwise her mouth had healed. Vaginally, her cervix was con- 
gested and slightly eroded. Vagina congested. No ulcers seen. Although 
not entirely cured, she insisted upon leaving the hospital, which was re- 
luctantly granted. 



A CASE OF LATENT DISSECTING ANEURISM OF THE 
AORTA AND RUPTURED SACCIFORM ANEURISM. 

Lefferts Hutton, M.D., and J. Gardner Hopkins, M.D. 

The following case is presented on account of the unsuspected find- 
ings at autopsy. 

Mrs. E., married, age 52, born in the United States, occupation housework, 
entered the hospital March 25, 1911, on the service of Dr. Samuel W. Lambert 
She gave the following history : 

Chief Complaint. — Cough, fever, and pain in the right side. 

Present Illness. — Eight days ago the patient was suddenly seized with a 
severe shaking chill, lasting about five minutes. This was followed by fever, 
a dry, hacking cough, headache, and prostration. She also vomited several 
times. Twenty-four hours later she had another chill, not so severe as the 
first. This was followed by fever and a sharp, stabbing pain in the right side, 
increased by coughing and deep breathing. Her abdomen felt somewhat sore, 
and was distended. Since onset, the patient has been confined to bed, without 
much change in her subjective symptoms. 

Past History. — She had an attack of pneumonia twelve years ago, which 
lasted eight weeks. She has had winter cough for several years, with some 
shortness of breath on slight exertion, especially marked during past year. 

Menstruation was regular up to four years ago, when menopause occurred. 
One child was stillborn at term. No miscarriages. No children living. No 
history of syphilis obtainable. 

Habits. — Takes two cups of coffee daily. Does not use alcohol. 

On physical examination, we found a well-nourished woman, who did not 
appear acutely ill. She had moderate dyspnea, and was very slightly cyanotic. 
Her cheeks were flushed. She had no herpes and no jaundice. 

Eyes. — The pupils were equal, and reacted normally. 

Tongue was clean and moist Throat clear. The mucous membranes were 
normal. Teeth were in good condition. 

Heart — The apex was palpable in the fifth space, 14 cm. to left of the mid- 
line. The right border was beneath sternum. The first sound at the apex 
was rough and impure ; second aortic louder than second pulmonic. No 
murmurs were heard. 

Pulse. — Regular, and of good force. There was a slight increase in tension, 
and the vessel wall was palpable. 

Lungs. — Many fine, crepitant and moist rales were heard all over chest, 

180 



HEALED DISSECTING ANEURISM 



181 



front and back. Posteriorly, on the right side, between the scapula and 
vertebral column, there was a small area of slight dulness with bronchial 
breathing, voice and whisper. There were many fine, moist rales. 

Abdomen. — Slightly distended; no rigidity, masses, or tenderness made out. 

Liver and spleen did not percuss large. The edges were not felt. 

Extremities. — There was moderate edema of legs. 




Fig. 1. — Diagram showing position of the aneurisms as seen from behind. 
The sac of the false aneurism lies in front of the blind branch of the dis- 
secting sac. 



On admission, her temperature was 101.3° ; pulse 86 ; respiration 26. 
"White blood cells 21,000; polymorphonuclears 76 per cent; lympho- 
cytes 23 per cent; eosinophiles 1 per cent; hemoglobin 85 per cent. 



182 ST. LUKE'S HOSPITAL REPORTS 

Urine was acid, specific gravity 1.020. Very faint trace of albumin, 
no sugar, no indican, and no casts found. 

For the next six days her temperature slowly dropped from 102.3° 
to 99.4°. Her pulse ranged from 96 to 100, and her respirations from 
24 to 30. During this time the patient complained several times of 
"pain as food entered the stomach," although she took fluids very 
readily and in large quantities. On April 1, seven days after ad- 
mission, the physical signs had perceptibly changed. The right up- 
per lobe had almost entirely resolved; the right lower and left upper 
were clear, while below the angle of the left scapula there was an 
area of dulness with bronchial expiration and voice, and fine, sub- 
crepitant rales over entire lower lobe, indicating a beginning con- 
solidation of this lung. The leucocytes had risen to 25,000, the poly- 
morphonuclears were 80 per cent. Her temperature was 102° ; pulse 
96, and respiration 24. 

During the next five days patient complained of lumbar pain, 
which was relieved by either the hot-water bottle or codeine in moder- 
ate doses, and was thought to be due to the pleurisy. The physical signs 
of consolidation became more evident. The leucocytes ranged from 
20,000 to 15,000, the polymorphonuclears from 80 to 71 per cent ; tem- 
perature from 100° to 101°, pulse from 86 to 98, and respiration from 
24 to 28. On April 7, seven days later, the physical signs consisted of 
marked dulness, with diminished fremitus and distant bronchial 
breathing, from angle to base. Above this was an area of increased 
fremitus, bronchial breathing, and numerous rales. The possibility 
of an empyema was discussed, but as the temperature was 100.2°, the 
leucocytes only 11,000 with 68 per cent polynuclears, and the general 
condition of the patient was considered good, the chest was not ex- 
plored until thirty-six hours later, when a syringe full of clear fluid 
was obtained near the angle of the scapula. The cytological exami- 
nation showed polymorphonuclears 3 per cent, and lymphocytes 97 
per cent. 

From April 10 to 30, the physical signs of fluid remained the same. 
The chest was explored at frequent intervals with the same result; 
namely, a syringe full of clear fluid was obtained, but on substituting 
a cannula and suction for the needle only a few cubic centimeters more 
were obtained. The opinion prevailed that there were multiple small 
cysts, which were aspirated dry at each exploration, surrounded by 
an immensely thickened pleura. 

Three days before her death, the patient began to regurgitate solids, 



HEALED DISSECTING ANEURISM 183 

but managed to retain fluids. This regurgitation remained unaltered. 
The idea of an interlobar empyema still prevailing, the chest was 
again explored with the same result: 2 e.c. of clear fluid. 

Sixteen hours before death she complained of severe pain in the 
left side, which was unrelieved by codeine or heat. During the early 
evening she was restless and suffering from pain, which was relieved 
by codeine. The patient then slept for about six hours, awakening 
with severe pain between the ribs on the left side. This was not in- 




Fig. 2. — Diagram showing the position of the aneurisms as seen in cross 
section through the trunk. The diaphragm is represented by the double line 
surrounding the liver. 

fluenced by codeine. Thirty minutes later her pulse suddenly became 
weak and irregular, and her skin cold and clammy. There was no 
dyspnea, and no air-hunger, patient being conscious until the end. 
On a hurried examination, breath sounds could not be heard over 
left lower chest. Patient failed to respond to the usual hypodermic 
stimulation, and died forty-five minutes after onset of pain. 

The autopsy was performed the day after death. On opening the 
thorax, the anterior portion of the left pleural cavity was found to be 
filled with blood clot which extended about the root of the lung and 



184 ST. LUKE'S HOSPITAL REPORTS 

up over the apex, amounting to 600 c.e. in volume. From about the 
mid-axillary line backward the lung was firmly bound down to the 
chest wall with a mesh of fibrin 2 em. or more thick, which was satu- 
rated with a turbid yellow fluid. No origin of the hemorrhage could 
be found about the upper portion of the pleura, where the greater 
part of the blood was collected. In the left upper quadrant of the 
abdomen a large mass without definite boundaries was felt behind the 
peritoneum and above the left kidney. On section, this mass was 
found to lie behind the posterior portion of the diaphragm, and to 
consist of a large false aneurism lying between the diaphragm and 
the diaphragmatic pleura. The aneurism had ruptured upward into 
the pleural cavity, and on account of the dense adhesions the blood 
had been forced upward and forward around the root of the lung. 
The aneurism opened laterally from the aorta by a huge gap measur- 
ing 5 cm. vertically by 1 cm. antero-posteriorly. The remnants of the 
arterial wall could be traced out for a distance of 3 or 4 cm. into the 
wall of the aneurism. Beyond this point the sac consisted of dense 
connective tissue, and for the most part was filled with firm thrombus. 
It extended laterally 11 cm., practically to the lateral chest wall, and 
measured 11 cm. vertically by 5 cm. antero-posteriorly. 

The aorta also presented two other aneurisms. One of these was 
a fusiform dilatation of the ascending aorta, occupying the region of 
the fourth sinus. It was 5.5 cm. in diameter. 

The lesion of greatest pathological interest was a healed dissecting 
aneurism which involved the greater part of the descending thoracic 
aorta. Eleven cm. below the origin of the left subclavian there was 
a small opening in the left wall of the aorta through which a probe 
could be passed into an elongated sac in the wall of the vessel. This 
measured 2 cm. in average diameter, and extended about 2 cm. above 
the opening into the main vessel. A short distance (3 cm.) below this 
it branched, one branch communicating by a small opening with the 
neck of the ruptured aneurism described above, the other lying pos- 
terior to the neck of this aneurism and ending blindly a little below 
the level of the celiac axis. The total length of the sac was 13 cm. 
The lower portion of the blind sac was filled with a firm thrombus. 
The upper part of the lumen was free. Some portions of the wall 
were smooth and glistening, other portions showed atheromatous and 
calcareous plaques. The caliber of the tube was irregular and the 
wall showed nodules where it attained a thickness of 14 mm. It did 
not block the orifices of the intercostal vessels, all of which opened 



, 








Fig. 3. — Photomicrograph showing cleft in the media of abdominal aorta. 
Above is seen an atheromatous area in the intima and the linnen of the aorta. 

50 diameters. 




*•*£ - .«*?•- 



Fig. 4. — Photomicrograph showing almost complete obliteration of one of 
the vaso vasorum of the aorta. The vessel is surrounded by plasma cells 
and lymphocytes. 2G0 diameters. 



HEALED DISSECTING ANEURISM 185 

posterior to it. The aorta itself showed most extreme endarteritis, 
especially in the lower thoracic and abdominal portions. The changes 
were much more marked than is usual in cases of aneurism. There 
were many large calcareous plaques with sharp edges, between which 
the surface was deeply ulcerated. The orifice of the celiac axis, which 
lay a little below the main aneurism, was restricted to a diameter of 
2.5 mm., while the superior mesenteric just below this was dilated, 
measuring 7 mm. across. The right renal artery was very large, while 
the left renal was much contracted, the suprarenal on this side being 
unusually large, apparently in compensation. These vessels, beyond 
their origin, showed little evidence of disease, and the atheroma was 
confined chiefly to the aorta. 

The other organs showed little of note. The heart was hypertro- 
phied and the myocardium showed very slight evidence of fibrosis. 
The aortic ring was thick and calcareous, but not appreciably dilated. 
The valve leaflets were all slightly thickened, but appeared competent. 
The coronary trunks were free. The lymph nodes about the aorta 
were enlarged to a diameter of one to two centimeters. They were 
soft and homogeneous on section. Many of them were closely attached 
to the adventitia. The mesenteric nodes were also enlarged to a less 
degree. The lungs showed edema and emphysema. There were evi- 
dences of chronic passive congestion in the liver, spleen and kidneys. 

Section through the dissecting aneurism showed that it lay in the 
media of the aorta between the internal and external elastic lamella?. 
The elastic fibers of both these lamellae were fragmented and partly 
replaced by hyaline connective tissue. The adventitia was very thick. 
The walls of the vaso vasorum were thickened by fibrous tissue, and 
the endothelial cells were swollen. Some of the veins were entirely 
occluded by masses of pus cells. The vessels were surrounded by col- 
lections of plasma cells and lymphocytes. Large collections of these 
round cells were found elsewhere in the adventitia, but none of the 
foci contained giant cells or showed central necrosis. Spirochaetae 
could not be demonstrated by Levaditi's method. The picture was 
extremely suggestive of syphilis, but did not warrant an absolute 
diagnosis. The intima of the aorta was greatly thickened by masses 
of tissue staining faintly with eosin and containing few stainable 
nuclei. There were areas of calcification. The inner wall of the dis- 
secting aneurism showed similar degenerative changes. The lumen 
was lined in part with a layer of flat cells resembling endothelium. 

Similar lesions were found in the abdominal aorta. On cutting 



186 ST. LUKE'S HOSPITAL REPORTS 

this vessel after fixation splits were seen in the wall, apparently not 
artifacts. In section these splits were seen to be in the media between 
the two elastic lamellae. The clefts were traversed diagonally by 
strands of unruptured fibers. There were smaller clefts in the intima. 

Changes of this type were first referred to by Rokitansky, with 
some reserve, as the possible cause of dissecting aneurisms. Recently 
Babes and Mironescu described a very similar condition, which they 
termed "dissecting aortitis," in two cases of dissecting aneurism. It 
seems highly probable that the degeneration of the media in this case, 
which led to the formation of large splits in the wall, either intra 
vitam or, under very slight stress, post mortem, explains the formation 
of a dissecting aneurism. The perforation of an atheromatous ulcer 
in the intima would expose this weakened portion of the wall and the 
blood would then force its way along this zone of the media with 
very little resistance. 

A healed dissecting aneurism is a rare lesion. In 1896, Adami was 
able to collect thirty clearly described cases and five other probable 
cases of this lesion. In the literature since that time we have found 
six cases. There are doubtless many others which have not been re- 
ported. Partial rupture of the aorta with the formation of a dissect- 
ing aneurism is relatively not uncommon, especially in medico-legal 
work, but the lesion usually terminates fatally within two or three 
days. The most common point of rupture is in the neighborhood of 
the aortic ring, and the sac may extend well down into the iliac ves- 
sels. It may end blindly or may establish a secondary communication 
with the aorta. If the patient survives the first shock, a blood flow 
may be established through the aneurism. It may carry a fair pro- 
portion of the blood stream and some of the large branches of the 
aorta may originate from it. These healed aneurisms are usually lined 
with a fairly well developed intima. 

Their incidence is somewhat late in life, most cases being between 
forty-five and fifty-five years of age, and they occur in females about 
as often as in men. Three factors are concerned in their production, 
probably in varying degree in different cases : trauma, arterial disease, 
and hypertension. No one of these factors is constantly present. 
Cases of rupture have been reported in arteries apparently normal in 
very powerful individuals during exertion. On the other hand, cases 
where the heart is small and shows brown atrophy, and where the 
blood pressure could not have been excessive, may rupture if the 
arterial disease is marked. Some cases have developed apparently 




«<* 



Fig. 5.— Photomicrograph showing endothelium lining the dissecting aneurism. 

200 diameters. 



HEALED DISSECTING ANEURISM 187 

while the patient was in bed being treated for some other ailment, so 
that trauma and exertion are not essential features. The arterial 
changes are not usually so extreme as in this case. Degeneration of 
the media is probably the essential feature. It is possible that the 
"dissecting aortitis" mentioned above may be found to be the under- 
lying cause in most cases. 

References. — Adami, Montreal Medical Journal, 1896, xxiv, 945 ; and xxv, 23. 
Babes and Mironescu, Beitrage f. path. Anat. (Ziegler), 1910, xlviii, 221. 
Rokitansky, Lehrb. d. path. Anat, 1855, 3d edition. 



REPORT OF A CASE OF CHRONIC ULCERATIVE COLITIS, 
WITH SIGNS AND SYMPTOMS OF ADDISON'S DISEASE. 

Edward N. Packard, M.D. 

Service of Austin W. Hollis, M.D. 

A. M. — Housemaid, German, aged 51, widow. Admitted August 9, 1911. 
Died October 25, 1911. 

History on Admission. — Chief Complaint: Vomiting, pains in legs, cramps 
all over body, and loss of strength. 

Family History. — Father died, aged 56, of rheumatism ; mother, at 57, dur- 
ing menopause. Three brothers and one sister all living and well. Hus- 
band was killed in an accident. No tuberculosis in family. 

Past History.— Has had no children, no miscarriages. Has always been 
healthy except for colds, etc. Diseases of childhood not remembered. Menses 
irregular for 18 months. 

Personal Habits.— Drinks about a cup of tea with a meal. No beer or 
whiskey; always worked fairly hard until present illness. 

Present Illness.— About 2 months ago, at time of her menses, patient was 
very nauseated and vomited a great deal, and this has persisted until present 
time. About 10 days later, patient began to have cramps in different parts 
of the body. Then, lately, has been losing strength, and her head and body 
feel as if they were too heavy for her legs. Her appetite has been very 
poor all summer, and she has lost a good deal of weight. Patient complains 
of nervousness, which has been growing more marked. About 3 weeks ago 
a rash appeared on lower part of extremities; this has gradually extended 
upward. 

Physical Examination.— Patient is a large woman, who has evidently lost 
some weight, the skin hanging loosely on body. Pt. does not appear acutely 
ill. No dyspnoea, cyanosis, or jaundice. The skin is of fair color, except 
following named spots, where skin appears darker than normal : eyelids, neck, 
armpits, hands and wrists, nipples, navel, inguinal regions, external geni- 
tals, and membrane of vagina. There is no pigmentation of mucous mem- 
brane of throat or cheeks. On arms, chest and legs is a raised eruption 
composed of small papules, in places confluent, and in other places partially 
circinate. This eruption is of a slight reddish tinge and feels lumpy. The 
eruption itches, and in places the top of the papule is scratched off. 

Eyes.— Pupils equal and react. 

188 



ULCERATIVE COLITIS SIMULATING ADDISON'S DISEASE 189 

Tongue.— Clean. 

Throat— Negative. 

Teeth and Gums.— In rather poor condition. 

Chest— Good development, fair expansion. 

Heart.— No localized apex impulse. Sounds heard best in 5th space, 
Sy 2 inches from m. 1. Left border 4 inches out. Sds. of good quality ; no mur- 
murs or accentuations heard. 

Pulse.— Regular, fair size and force; vessel wall not thickened. 

Lungs. — At rt. post, base, there are a few sub-crepitant rales heard on 
deep inspiration. 

Abdomen.— Normal. 

Extremities. — K. J. not obtained. Very slight edema. Some muscular 
weakness. No paralysis or atrophy. 

After the patient's admission to the hospital, she vomited daily for a 
week. The test-meal showed a low total acid and no free Hcl. Her gastric symp- 
toms gradually improved. Occasionally, throughout her sickness, she vomited 
and complained of gastric distress. The patient had blood in the stool almost 
constantly. The movements were never watery, but were of a brown fluid 
character containing clots of blood. She never had more than 5 stools a 
day. Often for days no blood was seen. She had periods of constipation. 
Her weight for 2 months varied but little, averaging 125 pounds, but for 
a few days before death, her weight fell to 110 pounds. The blood count 
was normal, except for 5% eosinophiles. Parasites were not demonstrable. 
Rectal examinations were negative, and no definite cause for probable ulcera- 
tion could be found. The urine 1012, trace albumen, no sugar, few hyaline 
and granular casts. On admission, a trace of indican. Wassermann reaction 
negative. For 3 days preceding her death the temperature was 94°. The 
autopsy revealed a chronic ulcerative colitis of an extent not appreciated while 
she was under observation. 

This case also presented the following interesting features: signs and 
symptoms of Addison's disease, an extensive eruption, and a suppurative 
skin lesion. 

As noted in physical, there were fairly well marked areas of pigmen- 
tation. These areas gradually paled out, except in axillae. The brown skin 
of hands desquamated during skin eruption described below. The skin of 
whole body was darker than the average normal individual's, but patient 
said her skin had always been of dark hue. She had lowered vaso-motor 
tone with blood pressure in 95 Hg. For a while she was able to sit in a chair, 
but later her weakness increased rapidly until her death. The gastric 
contents showed low total acid and no free Hcl, also absence of knee-jerks, 
found in cases of Addison's disease. The autopsy showed no pathological 
change in the suprarenals. 

The eruption noted in physical gradually spread until the whole body, in- 
cluding the face, was involved. The eruption gave a diffuse, dusky red, 
slightly raised appearance. Margins indefinite. In places it was lumpy. It 
itched. No vesicles or crusts formed. No exudation. It gradually faded, 
the skin desquamating in fine particles. 



190 ST. LUKE'S HOSPITAL REPORTS 

At about the time the eruption was disappearing, small superficial, pain- 
ful lumps appeared in axillae. These contained pus and were opened. The 
suppuration became extensive and the patient was transferred to the surgical 
ward. The count was 17,000, P. 87.5, L. 12.5, E. 1. Later, small punched- 
out ulcers with irregular, overhanging edges, and bases covered with exuda- 
tion, appeared in pubic region. Also numerous small pustules on eyelids, 
end of nose, and anterior chest. At one time, 35 abscesses were counted. 

Before her death, fine crackling rales were general over both lungs. The 
blood count was 35,000, P. 92, which was explained at autopsy. The whole 
suppurative process probably secondary to the ulcerative colitis. 

Autopsy Findings : Body of middle-aged woman, appears somewhat emaci- 
ated, cheeks sunken. In axillae are several ulcers y 2 cm. in diameter, with 
raised thickened edges and thick purulent exudate on granulating base. On 
tip of nose and at inner canthus of left eye are pustules covered with crusts. 
There are a number of healing ulcers similar to those in axilla? in pubic 
region, and one or two more over anterior surface of chest. Also two scars 
on chest of healed ulcers. There is a diffuse brownish pigmentation of the 
skin most marked in the axillae. 

Peritoneum.— Shows minute black flecks beneath the parietal surface and 
the omentum is of dull grayish color. 

Pleurae. — Following the line of several intercostal arteries are similar 
streaks of pigment beneath the pleura. Dome of diaphragm reaches to 3d rib 
on either side. 

Lungs (390 gms., 450 gms.).— Voluminous and rather firm at bases. Apices 
punctured with old scars but show no active tuberculosis. Bronchi inflamed 
and contain creamy pus. Bronchial nodes enlarged and black. 

On section right lung shows numerous miliary abscesses filled with creamy 
pus scattered throughout lower lobe. The left shows a few similar abscesses 
and numerous patches of gray granular consolidation. Except for these 
patches, the lungs are moist, and considerable fluid is readily expressed from 
the cut surface. 

Heart (330 gms.).— Small, covered with thick layer of yellow fat. Muscle 
brown. Cavities filled with chicken-fat clot. Valves normal. A ring of 
atheromatous thickening about base of aorta, and numerous patches in the 
coronary trunks. Coronaries tortuous. 

Spleen (90 gms.).— Normal size, soft. Malpigian bodies distinct. 

Kidneys (60 gms., 75 gms.).— Very small capsule strips readily leaving 
smooth surface. Cortex thick, of pasty, very pale yellow color; markings 
not well made out; medulla normal. 

Suprarenals. — Left softened by post-mortem change. Right appears quite 
normal. 

Bladder.— Normal. 

Uterus.— Cervix filled with mucus. Wall contains a few small fibroid 
nodules. 

Adnexa.— Normal. 

Liver (1,096 gms.).— Normal size. Pale and mottled, with bright yellowish 
areas. Gall bladder contains thin turbid bile. Wall not thickened. Small 



ULCERATIVE COLITIS SIMULATING ADDISON'S DISEASE 191 

stone impacted in mouth of cystic duct, but bile may be expressed into duode- 
num. 

Pancreas.— Largely replaced by fatty tissue. Islands of pancreatic tissue 
appear normal. 

Intestines. — Small bowel normal throughout. At ileo-caecal valve is ulcer 
•with thickened base which throws it upward into the lumen, and along en- 
tire ascending colon are similar ulcers about 2 or 4 cm. by 0.5 cm. with long 
axis running around the gut. They do not appear to penetrate the muscu- 
laris, which is greatly thickened so as to throw the ulcer into the lumen like 
a fibrous ridge. A few thickened spots with beginning ulceration at the 
center are found in the descending colon. The retroperitoneal nodes, near 
the caecum and to right of vertebrae, are enlarged, soft, and uniform deep black 
on section. The nodes in the mesentery are softened, semi-fluid and brownish. 
The panniculus was well developed, 4-6 cm. thick, and composed of intensely 
yellow fat. 

Anatomical Diagnosis.— Chronic ulcerative colitis, chronic parenchymatous 
nephritis, left broncho-pneumonia, miliary abscesses of both lungs, subacute 
cholecystitis, multiple ulcers of skin. 

Bacteriological. — Smears and cultures from lung abscesses showed Gram- 
positive staphylococci in pure culture. 



PNEUMOCOCCUS SEPTICEMIA. 

A. E. Neergaard, M.D. 
Service of Austin W. Hollis, M.D. 

Miss M. D., domestic, age 21. Patient in Minturn III, from Novem- 
ber 6, 1911, to November 7, 1911. Diagnosis — Pneumococcus septicemia ; con- 
genital pulmonary stenosis. Result— Died. 

Tbe patient was admitted at night, sent in with a diagnosis of typhoid 
fever. She died a few hours later, before complete examination had been 
made and before the clinical data could be collected. Hence the incom- 
pleteness of the following records. 

History on Admission.— The only facts obtained from the patient were, 
that she had been suffering for 8 days with headache and backache, with a 
fever varying from 101°-103°. She had coughed considerably, at times 
raising blood. 

Physical examination showed a fairly well-developed and well-nourished 
young woman, acutely ill. Her respirations were rapid and she was mark- 
edly cyanotic, but did not suffer from orthopnea. 

Her pupils were equal and reacted normally. She had internal strabis- 
mus. The tongue was coated. No cervical rigidity. Her chest was well 
developed, with good expansion. 

Heart. — Apex impulse in fifth space, about 5 inches out. No thrills. The 
sounds were embryonic in character, the heart action irregular. Almost 
masking the heart sounds, and heard all over the precordium, transmitted 
to both chests anteriorly and posteriorly, was a loud, harsh systolic murmur, 
heard with greatest intensity in the pulmonic area. The pulse was irregu- 
lar, of fair size and poor force. The lungs showed no abnormality other 
than a few rales at the bases posteriorly. Her abdomen and extremities 
were normal. 

The abnormal findings at the autopsy were as follows: 

Pericardium.— Contained 170 c.c. clear yellow fluid. An irregular patch 
of fibrin about 2 cm. in diameter was firmly adherent to the posterior sur- 
face of the right ventricle. 

Heart.— Weight 555 gms. The left auricle was very small, the right much 
dilated, while the right ventricle was greatly hypertrophied, its wall measur- 
ing 2.3 cm. in thickness. The tricuspid valve measured 11.5 cm. Its cusps 
were normal. The pulmonary orifice barely admitted the tip of the little 
finger, and measured 2% cm. One cusp showed 3 small areas, each about 

192 



PNEUMOCOCCUS SEPTICEMIA 193 

3 mm. in diameter, of reddish color, with rough, irregular surface, due ap- 
parently to a recent process. Otherwise, the cusps were normal. The left 
auricle and ventricle were both small. The mitral valve measured 10 cm., 
the aortic 7 cm. Their cusps were normal. The left ventricular wall meas- 
ured V/2 cm. in thickness. The coronaries were normal. Foramen ovale and 
ductus arteriosus not patent. 

Lungs. — Pleuritic adhesions and several small, hard, calcareous nodules 
at the right apex. At the anterior portion of the right base was a small, 
firm area (25 cm. in diameter), dark red, and raised above the surrounding 
surface with fairly sharp demarcation from the adjoining tissue. A vessel 
leading to this area was apparently occluded by a thrombus. In the upper 
posterior portion of the right lower lobe and in the anterior portion of the 
left lower lobe were similar areas, but no thrombosed vessels found. 

Liver.— Weight 960 gms. Surface very irregular. Capsule thick. Liver 
substance very firm on section, generally yellowish, with small red dots, 
broken up by heavy bands of connective tissue. 

Spleen.— Weight 240 gms. Fairly firm, deep red, trabecular prominent. 

Kidneys. — Weight, right 157 gms., left 180 gms. Capsule stripped with 
considerable difficulty, tearing away a portion of the tissue. Cut surface, 
opaque white with red markings. 

Uterus.— 11.5 x 5.5 x 3 cm. Cavity contained small amount of blood clot 

Findings in other organs insignificant. 

Anatomical Diagnosis.— Congenital pulmonary stenosis; acute endocarditis 
of the pulmonary valve; cardiac hypertrophy and dilatation; hydropericar- 
dium; infarction of the lungs; healed pulmonary tuberculosis; chronic primal 
congestion of liver and spleen; chronic diffuse nephritis. 

Bacteriological Diagnosis.— Smears from the pulmonary valves showed 
Gram + diplococci ; smears from the uterus showed Gram + diplococci and 
Gram + bacilli ; culture from the spleen was negative. 



Children's Service 



CHILDREN'S SERVICE FOR 1911 





Se 


X 


Results 




DISEASES DUE TO MICRO-ORGANISMS 

INFECTIVE DISEASES 




e 

"3 

a 


•a 

U 

s 



> 

u 
0. 

a 


> 


a 

a 

d 
P 


s 


■ 

"3 

Eh 


Cerebrospinal meningitis 


1 
1 
1 










1 

1 


1 


Diphtheria 


4 
2 
1 
1 
1 
2 
2 

" i 
l 


4 
1 

1 

- '*2 

"i 
2 


2 


1 


5 




3 
1 






1 






1 






1 






2 




2 
1 
2 


2 


2 




4 




1 








2 




1 
1 




1 
1 

8 

1 


1 


Syphilis (congen.), mucous patches around anus. 




1 


Syphilis (congen.), secondary, circinate syphil- 


1 

1 
2 


1 


Tuberculosis of lungs, indigestion, otitis media, 










1 


Tbc. meningitis, general miliary the, ruptured 


8 

1 
1 
4 

1 






2 


10 
1 






"7 
1 


1 




1 




3 


7 








1 














ALIMENTARY SYSTEM 

INTESTINES 

Colitis 


15 

2 


30 

"i 
.. „ 

13 

1 
1 

"2 


19 

' i 
1 

1 

17 

1 


8 

1 


5 


13 

1 


45 
2 




1 




1 








1 










1 




12 


6 


1 


1 


25 




1 




2 

1 
5 

1 
1 

1 
1 






3 


3 




1 
2 






1 




1 




4 
1 


7 




1 




' i 


1 

' i 
1 






1 




1 






1 
1 










1 










10 




PHARYNX 


27 


20 
1 


27 

1 


9 


1 


47 
1 


Retropharyngeal abscess, acute rhinitis, acute 


1 
1 






1 


1 




1 
1 


2 
1 






2 










1 
















2 


3 


4 






1 


5 



197 



198 



ST. LUKE'S HOSPITAL REPORTS 



ALIMENTARY SYSTEM — Continued 


<1> 


a 

fa 


d 


a 


P 


-a 

s 





STOMACH 


1 
2 


' i 

2 


1 
2 








1 










2 








1 


1 




3 

1 


5 
1 






5 










1 










CARDIOVASCULAR SYSTEM 

BLOOD 


7 

1 


3 

1 


9 

1 






s 1 


10 
1 














1 

2 

1 

1 


1 






1 


HEART 

Mitral insufficiency and stenosis, tricuspid insuffi- 

Pericarditis, mitral insufficiency, ascites 

Pericarditis, mitral insufficiency, chorea, fibrinous 


3 






3 




1 
1 

1 


1 










1 


1 
' "2 








1 


Rheumatic endocarditis, aortic and mitral insuffi- 


1 




1 
2 




1 




2 








3 

1 




LYMPH GLANDS 


5 


4 

1 
1 




6 


1 


9 
1 








NERVOUS SYSTEM 

BRAIN 


1 






1 


1 
1 


















1 

1 
1 






1 


1 


DISEASES OF THE MIND 






3 

1 

4 


1 
1 


1 




1 


NERVOUS DISEASES OF UNKNOWN ORIGIN 


2 
4 


3 

1 


4 


2 





2 

7 




1 








SPINAL CORD 


4 
1 


4 


4 
1 




8 
1 














1 

1 


"i 
1 

1 


1 

"i 

1 








1 


OSSEOUS SYSTEM 

BONES 


1 
1 
2 






1 




1 


Rickets 


1 
1 


2 




1 


Rickets, tetany, laryngismus stridulus, gastro- 








1 














RESPIRATORY SYSTEM 

BRONCHI 


3 

5 


3 
3 


2 

8 


4 






6 

8 



PEDIATRIC STATISTICS— 1911 



199 



RESPIRATORY SYSTEM— Continued 




a 


6 


0. 

a 


P 


•a 

s 




EH 


Bronchi — Cont. 
Bronchitis, eczema 




1 
""i 


l 








1 


Bronchitis (acute), inguinal hernia, rickets.... 
Laryngitis, pertussis 


1 


1 
1 






1 
1 


Spasm of larynx, asphyxia, tetany 


1 




1 
1 

1 

3 
1 

1 


1 














LUNGS 

Abscess of lung 


7 


5 

1 


9 


2 

1 




12 

1 


Atelectasis, prematurity 


1 
1 
4 


1 




*2 

1 


"2 


1 


1 


1 


Pneumonia (broncho-) 


6 


Pneumonia (broncho-), ac. colitis 


1 


Pneumonia (broncho-), inguinal hernia 


1 
1 

1 

1 
1 
1 
1 




1 




1 


Pneumonia (broncho-), meningitis 


1 


Pneumonia (broncho), otitis media, conjunctivi- 
tis, eczema, inflammation of Meibonian gland 




1 






1 


Pneumonia (broncho-), pericarditis 






1 

1 
1 

9 


1 


Pneumonia (broncho-), pertussis 










1 


Pneumonia (broncho-), pertussis, otitis media... 










1 








3 


1 


1 






PLEURA 

Pleurisy with effusion 


13 

1 
2 


4 


3 

1 


2 


17 
1 




3 






3 






ORGANS OF SENSE 

ORGAN OF HEARING 

Otitis media, ac. mastoiditis, septic meningitis.. . 
Otitis media, malnutrition 


3 
1 


1 
2 


1 
1 


3 

1 


1 


1 


4 

1 
2 


Otitis media, malnutrition, broncho-pneumonia. . 


1 

1 
1 


1 


Otitis media, nephritis 




1 






1 


Otitis media, scurvy, pertussis 


1 
2 

2 






1 






TEGUMENTARY SYSTEM 
Chronic ulcer of neck, malnutrition 


4 

1 
1 
1 
1 

1 


2 
1 

' i 


2 

"i 
1 

2 


1 
1 


1 


6 
1 




2 




1 










1 










2 












URINARY SYSTEM 

KIDNEY 


5 
1 


2 

"i 
1 


4 

1 

1 


2 


1 




7 
1 










1 


Pyelitis, chronic constipation 




1 






1 














1 

1 
1 


2 

' i 


2 


1 

1 

1 






3 


CONGENITAL MALFORMATIONS 


1 




1 




1 
1 






1 




1 
3 


1 




DEFORMITIES 
Flat foot 


3 
1 


1 




1 

1 




4 
1 






1 






1 




1 



200 



ST. LUKE'S HOSPITAL REPORTS 





2 


a 

fa 


u 


a 

a 


d 

P 


0) 

5 


4J 

o 


INTOXICATIONS AND POISONS 


1 




1 








1 














1 

1 


1 


1 








1 


INJURIES 




2 




2 






MISCELLANEOUS CONDITIONS 


1 

4 

1 


1 

2 

1 
1 
1 
4 


4 

1 


2 

1 


2 


i 
l 


2 
6 




2 




1 












1 




4 

1 
1 


8 






8 








i 


1 






1 






1 














11 


9 


14 


3 




3 


20 



Orthopedic Service 



ORTHOPEDIC SERVICE 



DISEASES OF THE SPINAL CORD 





T3 






O) 




t3 






o> 






> 


a 




& 


ti 


•a 


a 


a 


£> 


5 



Paralysis (ant. tibial) 

Poliomyelitis (anterior) 

Poliomyelitis (ant.), paralysis. 



DISEASES OF THE BONES 



Fracture of femur (malunion) ....... 

Fracture of hip (ununited), nephritis. 

Fracture of tibia 

Rickets, bow-legs, knock-knees 

Potts' disease 



DISEASES OF THE JOINTS 

Osteo-arthritis of ankles, knees, elbows, wrists and fingers. 

Pneumococcus arthritis of hip 

Pneumococcus epiphysitis 

Septic arthritis of hip and knee 



CONGENITAL MALFORMATIONS 



Dislocation of hip 

Malformation of femur. 
Spondylolisthesis 



DEFORMITIES 



Genu varum 

Genu valgum 

Hallux valgus 

Muscle-bound feet 

Pes planus 

Stiffness of elbow joint following fracture. 

Talipes equino varus 

Talipes equino valgus 

Torticollis 

Ingrowing toe-nail 



DISEASES DUE TO MICRO-ORGANISMS 



Tuberculous arthritis of hip 

Tbc. arthritis of knee 

Tbc. osteitis of hip 

Tbc. osteitis of hip, pulmonary tbc 

Tbc. osteitis of knee 

Tbc. osteitis of spine 

Tbc. osteitis of spine, hips and both knees. 



203 



4 
1 

2 
1 
1 
1 
2 
1 
1 
1 

15 



4 
1 
7 
1 
2 
2 
1 

18 



AN OPERATION FOR SECURING MOTION IN ANKYLOSIS 
OF THE ELBOW DESIGNED TO PREVENT THE SUB- 
SEQUENT OCCURRENCE OF FLAIL JOINT. 

T. Halsted Myers, M.D. 

All the older surgeons insisted upon the removal of large amounts 
of bone, both from the humerus and the ulna and radius if the ob- 
ject was to secure a movable joint after resection of the elbow. One 
and a half inches was about the distance that should separate the 
ends of the bones. Since the introduction of the method of interpos- 
ing between the bones, a flap of fascia and fat, or muscle, or animal 
membrane, it has not been considered necessary to remove so much 
bone. For instance : 

Goldthwaite, Painter and Osgood, writing in 1909, advise as follows, page 
248 : Open the joint by the posterior incision. Preserve the attachment of 
the triceps to the fascial expansion over the upper part of the ulna. Subperios- 
teal exposure of the condyles of humerus and the olecranon. Condylar sur- 
faces removed by saw, elbow flexed and ends of radius and ulna pushed up 
into the wound, where they can be reached easily. It is desirable to turn in 
a flap of fascia or fat, obtained from the neighboring tissues. Arm put up in 
internal angular splints for two or three weeks. Then gentle passive and active 
motion permitted. In two months a fairly good functional result may be 
expected. In some cases there will be too much lateral motion at the false 
joint, rendering the articulation more or less unstable. To control this a 
jointed leather splint, permitting flexion and extension, but holding the ends 
of the humerus and ulna together so that they cannot slip past each other 
laterally, has been employed. 

Kocher, Operative Surgery, 1911, p. 317, pays considerable attention to 
the conservation of the lateral ligaments. The external lateral ligament, 
with the attachment of the extensor tendons, and the capsule attached to 
the external condyle are separated subperiosteal^. If complete resection is 
to be performed, after dislocating the joint, the internal lateral ligament is 
separated subperiosteal^, along with the muscles, from the inner border of 
the ulna and the internal condyle of the humerus, and the ends of the bones 
are removed. In separating the lateral ligaments it is better to remove a 
shell of bone along with them, so as to preserve their attachment to the 
periosteum. The best results are obtained by interposing the supinator longus. 

Binnie, Operative Surgery, 1912, p. 996, prefers operating as follows : With 
osteotome, separate olecranon from humerus. Remove most of olecranon. 
Divide bony tissue uniting humerus to ulna and radius. Completely divide 

205 



206 



ST. LUKE'S HOSPITAL REPORTS 



lateral ligaments. Flex elbow acutely. With Gigli saw remove small portion 
of lower end of humerus. Remove articular surface of ulna, and model a 
new sigmoid cavity. If necessary, remove part of head of radius. Divide any 
bony tissue uniting radius to ulna, if possible preserving iinnular ligament. 
Smooth and shape opposing surfaces of radius and ulna. Interpose flap of fat, 
fascia and muscle. Trim edges of humerus. Cover its lower end and one 
inch of both anterior and posterior surfaces with flap of fat, fascia and muscle 
(anconeus, extens. carp. Ulnaris, etc.). Stitch this in place. Close wound 
with drainage. 





Fig. 1. — Tubby, Deformities, including Diseases of Bones and Joints, 1912, 
removes rather more bone, including the epicondyle and epit.hrochlea, the olecra- 
non and its articular surfaces, and part of the head of the radius, making a 
gap of iy 2 inches at least between ends in an adult. He interposes a strip 
of the anconeus between humerus and radius and ulna, and winds a strip of 
the extens. carpi rad. long, about radius, between it and the ulna. 

As to the best material to interpose between the freshened ends 
of the bones : While foreign bodies, such as plates of magnesium, ivory, 
etc., seem to have been generally discarded, many surgeons are using 
flaps of fat fascia and muscle from the neighboring parts. 

Aponeurotic flaps are too feebly nourished with blood to undergo 
transformation into bursal tissue, which is considered desirable (Hu- 
guier, Paris, 1905). Baer, writing in the American Journal Ortho- 
pedic Surgery, August, 1909, says : 

"In a majority of cases the interposition of living tissues is followed by a 
constant pain, due to pressure upon its nerve endings. While we may attain 
a certain degree of motion by the interposition of muscle or fascia, the motion 
is generally unnatural in character, and quite often results in an unstable joint 
The membrane which I use is from the pig's bladder, and is chromicized, so as to 
remain intact about forty days. This is thin and pliable enough to allow of 




Fig. '2. — Skiagraph of right elbow taken a year after operati 




Fig. 3. — Skiagraphs of left elbow taken a year after 
operation. 



ANKYLOSIS OPERATION WITHOUT FLAIL JOINT 207 

easy adjustment within the joint, and will remain there beyond the period of 
bone or fibrous formation." 

Transplantation of living cartilage (Weglowski, Centralblatt fur 
Chir. 1907, No. 17) in the treatment of ankylosis, and transplantation 
of an entire living joint (Buehmann, Centralblatt fur Chir., 1908, No. 
19) have not been done sufficiently often to enable one to estimate 
their value. 

The operation I wish to describe is in line with the tendency to 
sacrifice as little bone as possible, by the interposition of animal mem- 
brane, and to especially preserve the leverage of the muscles about the 
elbow, and prevent too great relaxation of the joint. 

In the early part of 1910 I saw a girl, fifteen years of age, most of whose 
joints were partially or completely ankylosed by an infectious osteoarthritis, 
which had attacked her ten years previously. The deformities resulting had 
been corrected, and the joints manipulated, several times, under anaesthesia, 
by different men, after the active stage of the disease had subsided; but the 
ankyloses gradually recurred. Nothing had been done for the past five years. 

As there were no signs of active disease, and both elbows were ankylosed 
at 140°, but pronation and supination were fairly good, and as she had a little 
motion in her fingers, and about half the normal amount in her shoulders, I 
decided to try to mobilize her elbows, as that would enable her to feed and 
dress herself. 

May 21, 1910. Ether. After Esmarch bandage had been applied, the right 
elbow was exposed by a vertical incision down to the bone, along the outer 
edge of triceps tendon and olecranon process. The triceps tendon was freed 
from the process for about an inch, but its periosteal attachment not divided. 
All the soft tissues were then retracted en masse, with periosteum, to the outer 
and inner sides of the joint, but only as far as the condyles. The ulna nerve 
was displaced inward to the edge of the condyle. This dissection gave free 
access to the posterior part of the joint, and a truncated wedge-shaped section 
of the lower middle part of the humerus was removed easily with chisel. The 
joint was then forced to a right angle position, and the rest of the bone 
attached to head of radius and to ulna was removed with rongeurs, and all 
surfaces made smooth. Cargile membrane was then placed in front, under 
and behind the edges of the humerus. The ulna nerve was replaced, and the 
wound closed without drainage. A plaster splint was applied from fingers 
to neck, the elbow being held at 80°, in mid position between pronation and 
supination. 

Eighteen days later, first dressing. Primary union. Elbow passively flexed, 
without pain, to 40°, and extended to 135°. Elbow then fixed at 40°. Ulna 
anaesthesia noted at first is less marked. Two weeks later a sling was sub- 
stituted for cast, and child encouraged to use the arm. 

In September the anaesthesia had disappeared entirely, and the elbow had 
a range of motion from 150° to 30°, and about 15° of both pronation and 
supination. 



208 ST. LUKE'S HOSPITAL REPORTS 

October 3, 1910, the same operation was done on the left elbow, with 
the exception that the incision was carried down the inner side of the olecra- 
non, in order to make the approach to the ulna nerve more direct. This nerve 
was not displaced at all, but was subjected to rather severe pressure by the 
retractors, which may account for the anaesthesia In this case The joint was 
found in about the same condition as the right had been, and was treated in 
the same way, but instead of Cargile membrane, Johnson and Johnson's 
chromicised pig's bladder (Baer's membrane)) was used to cover the edges 
of the humerus. Wound then closed, without drainage, and elbow fixed at 
80° by plaster splint extending from fingers to neck. 

Nine days later cast was removed. Primary union. Cast reapplied. Oct. 
20th, cast permanently removed. Extension to 120°, flexion to 60° possible, but 
more pain and resistance than in previous case. Ulna anaesthesia. Sling ap- 
plied ; massage and passive motion ordered daily. Position to be changed 
each day. 

Dec. 6, 1910. The child has very good use of the right elbow, and can feed 
herself and reach all parts of her head. The left elbow can be extended to 
140° and flexed to 40°, but is still somewhat tender, though each week less so. 
The ulna anaesthesia is still present. 

March, 1912. Report received from this child states that in the left arm 
the range of motion is from 145° to 60°, with pronation and supination of 15° 
each. In the right elbow the range of motion is from 135° to 40°, with an 
equal amount of pronation and supination. There is still some ulna anaesthesia 
in left hand. The child can dress herself without assistance. 

The object of this method of remodeling the joint is to remove the 
opposing bone surfaces a considerable distance from each other, and 
yet not destroy the strength of the articulation, as is generally done 
when the lateral ligaments are divided, and the condyles, the attach- 
ments of the pronators and flexors on the inner side, and the extensors 
on the outer side are removed. In the usual operation of excision, 
the posterior support and leverage of the olecranon is also destroyed. 
In this operation the ligaments on all sides of the joint are preserved. 

The operation may not be suitable for tubercular cases which have 
become ankylosed, but seems to meet the requirements in joints anky- 
losed from any of the acute infections, or from the various forms of 
atrophic or hypertrophic osteo-arthritis, and in some cases of ankylosis 
after fracture about the joint with deformity and excessive callous 
formation. 

The enclosed sketch shows the amount of bone removed; that part 
included by the heavy lines. 

The skiagraphs taken Nov., 1910, show marked changes in the joints, 
and also how little can be learned from such a picture about the 
amount of motion possible in that joint. 



Otological Division 



THE RADICAL OPERATION WITH THE APPLICATION OF 

THE PRIMARY SKIN-GRAFT, FOR THE RELIEF OF 

CHRONIC MIDDLE-EAR SUPPURATION— WITH 

REPORT OF CASES. 

Edward Bradford Dench, M.D. 

I have already written so fully, on previous occasions, upon this 
subject, that an article of the same character, in the St. Luke's Hos- 
pital Reports, may seem rather out of place. The fact, however, re- 
mains that in spite of the excellent results obtained in cases of chronic 
middle-ear suppuration by the radical operation, with the application 
of a primary skin-graft, many surgeons still hesitate to resort to this 
procedure. 

I beg, therefore, to report two cases which I have operated upon 
in St. Luke's Hospital during the last few months, which demonstrate 
clearly the very excellent results which may be secured by this op- 
eration : 

The first patient was a boy, aged 11, who had suffered from a chronic 
discharge from the right ear for 7 years. The boy was anaemic, his general 
condition being much below normal, although no causes other than that of 
the persistent aural suppuration could be found to account for the impaired 
general health. An examination of the right ear showed an extensive de- 
struction of the membrana tympani, with granulation tissue present. This 
granulation tissue evidently had its origin in the tympanic vault. A por- 
tion of the internal wall of the middle ear was dermatized. The low whisper, 
upon the right side, was heard only at 4". There was no evidence of any 
labyrinthine involvement. On October 24th the radical operation was per- 
formed. The mastoid cells were well developed, and extensive caries was 
found throughout the entire mastoid. This caries extended posteriorly to the 
sinus groove, and the lateral sinus was exposed during the operation. 

The complete radical operation was performed, all the mastoid cells were 
obliterated, and the mastoid cells, middle ear and external auditory meatus 
were thrown into one large cavity by the taking down of the posterior meatal 
wall. Particular care was given to the obliteration of the hypotympanic 
space by lowering the level of the floor of the external auditory meatus, 
while the posterior tympanic space was obliterated by carefully removing 

211 



212 ST. LUKE'S HOSPITAL REPORTS 

the posterior canal wall, as far backward as possible, without injury to the 
facial nerve. The nerve was exposed by this procedure, but not injured. 
The external auditory meatus was enlarged by cutting a tongue-shaped flap 
from the concha. Cartilage and connective tissue were removed from this 
flap, and the flap was then folded backward and upward and stitched to 
the raw area on the posterior aspect of the auricle. The operation cavity 
was then exsanguinated by firmly packing it with a strip of gauze saturated 
in a solution of adrenalin chloride, of a strength of 1-1,000. All superficial 
hemorrhage was controlled by ligatures. The entire cavity, formed by the 
exenteration of the mastoid and middle ear, was then lined with two Thiersch 
grafts. 

Ordinarily, one graft is used to line this cavity, but it was impossible, 
owing to the small thigh of the patient, to obtain a single graft large enough 
for this purpose. The grafts were laid over the bone and made to apply 
themselves exactly to the irregularities of the surface by introducing a 
pipette beneath the grafts, and then exhausting the air. This procedure 
permits the graft to adapt itself to the irregularities of the bony surface. 
The grafts were held in position by small pledgets of sterile cotton packed 
into the cavity. The posterior wound was then closed completely, and a 
third graft was applied to the meato-conchal margin, the graft being held 
in position by a light packing of sterile gauze. The operation was com- 
pleted by the application of a sterile dressing. The sutures in the posterior 
wound were taken out on the second day, and the pledgets holding the 
graft in position were removed about 5 days after the operation. The 
grafts adhered perfectly, and the ear was completely dry 3 weeks from the 
time of operation. Two and a half months after the operation the whis- 
pering distance on the right side was 3 feet. 

The operation, in this case, was a perfect success, all discharge 
from the ear having ceased 3 weeks after the operation, and the 
hearing having been greatly improved. 

The second case was that of a young man, 25 years of age. When 2 
years old both ears discharged. There was no further aural trouble until 
8 years before I saw the patient, when both ears again discharged. For 
the past 8 years there had been an intermittent discharge from each ear 
whenever the patient had a severe cold in the head. Two weeks before I 
saw the patient, the left ear began to discharge rather profusely, and there 
was some pain in the ear. Upon examination, a large perforation was found 
in the right drum membrane, with partial dermatization of the mucous 
membrane of the middle ear. The ear was perfectly dry. Examination of 
the left side revealed some purulent discharge in the left auditory canal, a 
large perforation involving the lower portion of the drum membrane and 
the internal wall of the middle ear was swollen; there was slight sinking of 
the upper and posterior wall of the external auditory meatus, close to the 
drum membrane, and a sinus leading into the tympanic vault. The low 
whisper was heard 23 feet upon the right side and 5 feet upon the left side. 
The patient had a temperature of about 100° on the afternoon of the day 



RADICAL OPERATION IN MIDDLE-EAR SUPPURATION 213 

upon which I first saw him. There was no labyrinthine involvement demon- 
strable, except that the left labyrinth was slightly hyperaesthetic to the 
galvanic current. While the patient had no severe pain, there was a con- 
tinued feeling of discomfort in the ear, and 5 days after I first saw him, the 
radical operation was performed. The periosteum covering the mastoid was 
considerably thickened, and there was considerable caries in the mastoid 
cells. This caries was particularly well marked over the roof of the tym- 
panum and mastoid, and it was necessary to expose the dura in this region 
before all diseased bone was removed. The dura was slightly congested. 
The radical cavity was formed in exactly the same manner as in the 
previous case, the hypotympanic space being obliterated by removal of the 
floor of the canal, while the posterior tympanic space was also effaced by 
the careful removal of the posterior canal wall, close to the facial nerve. 
The meatal flap was formed in the same manner as described in the first 
case. The entire bony cavity was covered by a single Thiersch graft, held 
in place by pledgets of sterile cotton. The posterior wound was closed and 
a meatal graft applied. In 2 weeks' time the middle ear was perfectly dry, 
and the low whisper was heard at a distance of 15 feet in the operated ear.. 

These two cases, operated upon within a period of six weeks, show" 
the results that can be obtained in chronic middle-ear suppuration by" 
operative interference. They are simply examples of a series of 
nearly 200 cases, operated upon by the writer, in the same manner.. 
At the International Otological Congress, held at Bordeaux, in 1904, 
the author reported 98 cases, operated upon by this method. Since 
that time, I should say that an equal number of cases had been sub- 
jected to operation. With the perfection of technique, the results in 
later cases have naturally been better than in those cases operated 
upon at an earlier period, and I believe that now we can promise any 
patient suffering from a chronic middle-ear suppuration, not only a 
perfectly satisfactory result, as far as the otorrhcea is concerned, but 
also a satisfactory result as to the preservation of function of the 
organ. The only exception which I would make to this latter state- 
ment, is in those rare instances where, in spite of an aural discharge, 
the hearing is exceptionally good. In these cases, the hearing may 
become somewhat impaired as the result of the operation. In those 
cases, however, in which, as the result of the suppurative process, the 
hearing is greatly impaired, we can ordinarily promise the patient an 
improvement in hearing if he will submit to the operation. This fact 
is borne out in the two cases already reported. 

In a short article of this character, it would hardly be wise for 
me to discuss the dangers of chronic middle-ear suppuration. It may 
be well, however, to repeat the statistics which I mentioned in my 



214 ST. LUKE'S HOSPITAL REPORTS 

paper, read at Bordeaux. These statistics were as follows: The 
records of the New York Eye and Ear Infirmary, for 8 consecutive 
years, showed that 19,323 cases of suppurative otitis media were 
treated in that institution. During this time there were 218 cases of 
severe intracranial complications. In other words, one patient out 
of every 88 suffering from middle-ear suppuration, suffered also from 
some severe intracranial complication demanding operative interfer- 
ence. 

These statistics are, I think, sufficient to show how frequently a 
middle-ear suppuration causes some intracranial complication. The 
radical operation naturally removes all danger of subsequent intra- 
cranial involvement, and if, at the same time, we can promise the 
patient that the function of the organ will not be seriously impaired 
as the result of operative interference, we certainly are justified in 
recommending this procedure in all cases of intractable middle-ear 
suppuration. 



Pathological Department 



A NEW ERA IN MEDICINE IN NEW YORK. 

F. C. Wood, M.D. 

(Address given in Chicago, March, 1911, before the Alumni of 
Columbia University.) 

As most of you are aware, the educational problems before the 
colleges of this country are many and complex. A growing appreci- 
ation of the difficulties to be met is rapidly awakening, not only in the 
teacher but also in the public, some doubt as to the perfection of 
our methods and distrust as to the ultimate results as shown in the 
finished product, the college graduate. The problems are not wholly 
financial, as many seem to think; they lie far deeper in the innate 
spiritual qualities of the American race. Never has a people so pa- 
tiently tried to demonstrate that money will solve all problems of 
politics, art, or education, as our own. Never has a failure been so 
complete and absolute. We do not yet fully appreciate that money 
will buy neither loyalty, scholarship, nor genius, but only industry, 
no matter with how lavish a hand it be distributed. A faint glim- 
mering of light has occasionally penetrated the darkness when some 
incomprehensible foreigner has refused to abandon a comfortable 
teaching position in his native land for twice the salary and one-tenth 
of the appreciation he now enjoys. Because, with the expenditure 
of a few millions, a model manufacturing plant can be created in a 
year or two, people still seem surprised that the loyalty of a teaching 
body to a university and that intangible thing called tradition may 
be more valuable than much money; that the poorest paid and least 
known of the professors within a college's walls may have a world- 
wide reputation, while the specialist purchased at a high price from 
a rival institution seems chiefly known to the readers of the illus- 

217 



218 ST. LUKE'S HOSPITAL REPORTS 

trated editions of the Sunday newspapers, in which he publishes, in 
popular form, the preliminary reports of investigations, the final 
results of which rarely appear in print. It is not necessary to cite 
examples before such an audience. But the fact must not be forgotten 
that too often we think that a little more money would cure all 
academic ills, while really a thorough organization of the work of an 
already existing loyal and harmonious staff of teachers would accom- 
plish quite as much. 

But what of Columbia ? As graduates of the varied schools of that 
institution, you may ask what message I bear? Have we mistaken 
size for greatness or bartered a good name for newspaper notoriety? 
I can honestly say, No. The growth of the University has been re- 
markable, but, in general, wholesome, and its efficiency as a teaching 
institution is in every way better than in the previous decade. The 
most interesting changes of recent years in any department have 
been in the Medical School, long famous as the College of Physicians 
and Surgeons. The educational future of the institution has so re- 
cently been assured by an unusual combination of circumstances, 
coupled with a wise and generous gift of funds, that I shall confine 
my remarks chiefly to this aspect of the University's growth. 

As some of you may know, Columbia, on behalf of its Medical 
Department, is about to enter into an agreement with the Presby- 
terian Hospital, one of the largest private hospitals in New York, by 
which a much closer relationship is to be consummated than has 
hitherto existed between any of the New York schools and hospitals, 
an arrangement which permits the nomination by the College of the 
incumbents of the clinical and laboratory services of the Hospital. 
In return for this permission, which carries with it the use of the 
patients in the wards for the teaching of students, the College agrees 
to care for the scientific work of the hospital, the various heads of the 
purely laboratory departments becoming ex-officio responsible for the 
hospital work in their special fields. How great a change this is, and 
how much it means for the future of Columbia may not, at first sight, 
be very obvious, but I may safely say it promises a new era in Amer- 
ican medicine. It may seem a small thing as compared with the op- 
portunities which have been enjoyed by the English and German 
schools, by Johns Hopkins, and to a lesser extent by several of the 
Philadelphia medical colleges. And yet, it is the beginning of what 
may make New York City, as it should be, but is not, one of the great 
medical centers in this country. A short statement of the past and 



A NEW ERA IN MEDICINE IN NEW YORK 219 

present position of the Medical School may bring more clearly before 
you what the new arrangement means. 

Up to the year 1891, the College of Physicians and Surgeons, 
though nominally connected with Columbia University, was really a 
proprietary institution, though, through the generosity of the Van- 
derbilt family, it had been equipped with buildings which at that 
time were ample for its needs. Even then, however, it was felt that 
the school required a closer intellectual relationship with Columbia 
University, then beginning that remarkable expansion which has cul- 
minated in the great educational institution of some 7,000 students 
now existing in New York. An agreement leading to closer union 
was therefore carried out, and in 1901 the College was placed prac- 
tically under the absolute control of Columbia. In the meantime, 
much new construction had taken place, in order to bring the labora- 
tories up to modern standards. Through the generosity of Mr. and 
Mrs. W. D. Sloane, the Sloane Maternity Hospital was even then a 
model institution for the teaching of obstetrics. It has since become, 
in the past year, by the erection of a new pavilion, a complete Frauen- 
klinik, to use an expressive German term ; that is, obstetrics and gyne- 
cology are united in this hospital for women. In this phase of its 
work the school has always had all that it could desire. The Vander- 
bilt Clinic also has been a model for out-patient work, with a clientele 
so enormous that it has been difficult even to care for the patients, 
some 50,000 a year, much less to study each one carefully. Yet these 
were the only sources of clinical material for instruction absolutely 
under the school control. 

These changes, begun 20 years ago, seemed to place the college in 
a very strong position, especially as its faculty included most of the 
abler clinicians visiting the large hospitals. The condition of the 
scientific department has always been excellent, and the teachers in 
those subjects are well known the world over. I have only to recall 
the names of Prudden, Curtis, Cheesman, Hiss, Gies, Huntington, 
Richards, Herter and MacCallum to your minds. But despite the pres- 
ence of able men in the departments of medicine and surgery, the feel- 
ing has been growing stronger in recent years that they have lacked 
something that the laboratories possessed, that is a full control of their 
teaching material. It is only too true that while the laboratory in- 
vestigators of this generation are justly famous, the clinical teachers 
in this country, as compared with those of Germany, have contributed 
but little to the science of medicine. The surgeons, it is true, have 



220 ST. LUKE'S HOSPITAL REPORTS 

been ingenious, and have devised and perfected many operative 
methods now generally employed; but surgery is spectacular; it at- 
tracts endowments. Surgeons usually can obtain from hospital man- 
agers equipment costing many thousands of dollars, when the medical 
staff can hardly get a microscope, much less a polygraph. Surgery 
is so definite, so positive, and, one may say, so simple a field, that the 
surgeon has occupied the foreground in this country to the detriment 
of the physician. American surgery to-day is technically the best 
in the world, but medical research is still in its infancy. 

The reasons for this are many : First, we do not obtain in medicine 
the definite results that the surgeon does. We do not so evidently 
save lives. The general public suspects, and quite justly so, that many 
of the cures in medicine are due to fresh air, good nursing, and the 
healing power of nature, and not so much to the drugs administered. 
On the other hand, it is quite a simple matter for even a mediocre 
operator to remove an inflamed kidney, or a diseased ovary, or a 
tumor of the breast, and obtain satisfactory, even brilliant results. 
The physician works under different conditions. No one can claim 
to cure chronic Bright 's disease. Both kidneys are usually affected, 
and before a diagnosis is possible and any treatment instituted the 
organs have undergone serious and permanent changes. The treat- 
ment of cardiac lesions is a palliative one. We help the heart to do 
what it is trying to do naturally. We put the patient in bed and 
give the hard-worked muscle a needed rest. We regulate the diet, 
and, if need be, give cardiac stimulants. Nature does the rest. But 
we do not effect the permanent cure of many forms of heart disease. 
So, too, with many infectious diseases. Our powers are as yet ex- 
tremely limited. I may merely mention, as examples, pneumonia and 
tuberculosis. Our great victories over the latter are those of fresh 
air, good food, and prevention of the distribution of the virus. This 
brings us to the second reason why medical research in this country 
has not prospered. For the investigation of disease in human beings, 
a laboratory is necessary, and this laboratory is one in which the 
scientifically trained physician can study patients. Much can be done 
by means of animal experimentation, but dog medicine will never 
replace human medicine. The ordinary laboratory animals do not 
suffer spontaneously from the diseases in which we are most inter- 
ested. In fact, many of the important conditions cannot be induced 
in animals with any certainty. Therefore, while sufficient, and in 
some instances, ample facilities have been given pathologists, chem- 



A NEW ERA IN MEDICINE IN NEW YORK 221 

ists, bacteriologists, and even surgeons, the physician has long strug- 
gled with poor equipment, insufficient laboratory space, and lack of 
access to patients whom he can control. In other words, the medical 
school could offer no facilities for research in medicine, as it had no 
laboratories for such study; that is, no hospital. A third reason is 
that in general in this country there is no credit given and no financial 
reward offered for even the best medical research; the prizes go to 
the man with a large general practice. 

Not a little criticism has been directed for years toward hospital 
managers for closing the doors of hospitals to those who desired to 
study disease in the wards as they are studying disease in the labora- 
tory, and for giving appointments on the visiting staff to men who 
are purely practitioners of medicine, and not investigators ; and many 
comparisons have been made, to the disadvantage of this country, 
with the great opportunities existing in Germany, which are open 
not only to the Germans, but to any volunteer who is willing to give 
a reasonable amount of time in the wards. It is possible for any 
well equipped young American physician to go to Munich, for in- 
stance, and, if he will spend six months, to enter the wards of the 
great Fr. Miiller, and there study patients in a way which he cannot 
hope to do in America. Even the Johns Hopkins Hospital is more 
or less closed to outsiders, because of the necessity of using its ma- 
terial for its own students. But the young man comes back from 
Munich full of enthusiasm and scientific interest, and desirous of the 
same facilities that he has enjoyed there, only to find the doors of 
the hospitals closed against him. The great municipal hospitals can 
offer no advantages to the student of scientific medicine; they are 
poorly equipped, the scientific staff underpaid and overworked, and 
the executive staff still too largely under political domination — so the 
crowded ranks of the practitioners receive another recruit. 

And yet there is another side to the question. The managers of 
a private hospital are given money to be expended in the care of 
patients. They are trustees of this money, and consequently cannot 
spend it as freely as they could if the hospital were run on purely 
business principles. They can try no experiment, risk no cent of their 
funds. In consequence, the private hospital lags behind even the 
municipal institution in advancing medical science, and falls far short 
of what is and always can be accomplished by a private institution 
not dependent for its future upon donations. Then, too, it is im- 
possible to turn loose in the wards a large number of undergraduate 



222 ST. LUKE'S HOSPITAL REPORTS 

students. They are, in their enthusiasm, apt to over-examine and 
annoy a patient. It is difficult, for example, to keep an interesting 
ease of malaria in a ward ; every student and interne wishes to have 
a blood slide for his own collection. The hospital has to protect these 
people by limiting the number of students to each ward. It is difficult 
to convince them that they gain weight and strength by repeated punc- 
tures of their fingers. So, too, in gynecological work, it is impossible to 
have a large number of men examine a woman patient. In acute ap- 
pendicitis the fewer people who palpate the abdomen the better for 
the patient. The course of a severe pneumonia is not improved by 
having twenty men listen to the patient 's chest. So that the managers 
have a great deal on their side, and yet, largely due to the agitation 
and discussion which has been started by the alumni associations of 
the large New York hospitals, composed as they are of the younger, 
better trained physicians of the community, most of whom have 
also studied abroad, one after another of the great New York 
private hospitals has opened its wards to small numbers of selected 
fourth-year students. The P. and S., for instance, to-day can send 
fourth-year undergraduates into the wards of five of the large private 
hospitals, where they remain for two months, enjoying all the facilities 
offered to the residents, with the exception that they have no power 
to administer drugs. Much to the astonishment of the managers, 
not only has the death rate of the hospitals not increased by this 
introduction, but it has been found that the attending physicians 
are apt to give a great deal more time to their ward services than 
they did under the old regime. The cases are more thoroughly ex- 
amined, the patients are better satisfied, the histories are more care- 
fully taken, the house staff is relieved of unnecessary routine, and it 
is now the hospital which is beginning to ask for more teaching. This 
is as it should be, and the first result of this experiment, begun at 
St. Luke's Hospital, some three years ago, is the proposal of the 
Presbyterian Hospital managers to join with the P. and S. as offering 
the best results in the care of patients. To the managers, of course, 
scientific study is of less immediate interest, though they also are be- 
ginning to feel that the reputation that a hospital gets from the pub- 
lications and scientific fame of its staff brings it glory, and in that 
way, larger funds. In Germany — where, as any of you who have 
studied there know — the patients have less to say about their treat- 
ment than they have in this country; where autopsies are universal 
instead of exceptional; and where the system exists of placing the 



A NEW ERA IN MEDICINE IN NEW YORK 223 

patient under the care of eminent men who have made advances in 
chemistry or bacteriology or pathology, instead of those having merely 
a large private practice — the conditions are far ahead of what they 
can be in this country for some years to come. We may never reach 
the same freedom in handling human beings that now exists in the 
hospitals of Germany and France. Our attitude toward our patients 
is quite different, our feeling of responsibility to them is much greater 
here than it is there. All this makes more difficult the use of patients 
for thorough scientific study. The semi-military discipline of a Eu- 
ropean hospital cannot be imitated in America. Patients must vol- 
untarily offer themselves for study. We must ask a patient's per- 
mission before we can place him in a respiratory chamber; it is al- 
most necessary to obtain his permission before he can be put upon 
the somewhat irksome diet which is necessary for the complete chem- 
ical investigation of his metabolic peculiarities. These are some of 
the perfectly obvious and practical difficulties in medical investigation 
in this country, and there are not a few others patent to every labora- 
tory investigator. We cannot shut our eyes to them, and we must 
meet them with all possible patience, while at the same time safe- 
guarding our patients from annoyance and injury. This means a 
far greater supervision by the resident and visiting physicians than 
exists in Germany, but if such safeguards are offered, I think we 
can accomplish just as good work here as there, even though at a 
considerable disadvantage. 

The union of the Presbyterian Hospital and the P. and S., the 
close geographical relationship of the Rockefeller Institute, and the 
presence of the enormous hospital material now being offered for 
teaching purposes in New York City, therefore, opens up a new era 
to the P. and S., which, in the past few years, has been in great 
difficulties, both financial and clinical. The day of the old-fashioned 
clinical lecture, when the students sat in an amphitheater and watched 
the professors operate, or when the students made ward rounds and 
saw fifty patients without being allowed to examine one, has long since 
passed. Students must be taught in small numbers; no more than 
four or six men can be allowed to study a case. It means a great in- 
crease in the number of our teachers ; it means a great increase in our 
clinical facilities, before we can reach the ideal. The Presbyterian 
Hospital, in its new buildings, will construct ample laboratory fa- 
cilities for such scientific work; it will probably be the center of a 
large part of the undergraduate teaching of the school, and will offer 



224 ST. LUKE'S HOSPITAL REPORTS 

opportunities for the best type of medical and surgical research. But 
that is not the limit of a great hospital school such as must develop in 
New York, Chicago, and other large cities. For it is in the large 
cities that opportunities for teaching medicine exist. It is impossible 
to build a great medical school in a small town. A thousand hospital 
beds must be available for teaching purposes, if the student is to be 
thoroughly grounded, not only in medicine and surgery, but also in 
the important specialties, and such a large material is easily available 
if Columbia can further extend its hospital affiliations, even if the 
relationship is not so intimate as that with the Presbyterian. These 
are the conditions which we are now facing, and many problems must 
still be solved. 

A medical school must, primarily, teach undergraduates to be good 
practitioners. That is what the public wants; that is what the coun- 
try needs; well-rounded men who have seen a large series of cases, 
who are trained in all the fundamental sciences ; men who have had at 
least two years in college, more if possible, so that the curriculum need 
not be crowded with elementary courses in fundamentals; men who 
have had real training in biology and not merely a superficial course ; 
men who know something of mathematics, something of experimental 
physics, and a great deal of organic chemistry, and have a real read- 
ing knowledge of German, not only the ability to pick out a few 
sentences by the aid of a dictionary. Another function of a medical 
school is said to be to train teachers. I think this is wrong. Teachers 
are not made, they are born; only a small proportion of the men 
who study medicine is in any way fitted to teach, and to adapt a 
school for this special purpose is unnecessary. A still smaller pro- 
portion of those obtaining a medical education is fitted for productive 
research in medicine — the most complicated of all fields. Such men 
must have all the preliminary training that the future practitioners 
are given; they must also have opportunities to exert their natural 
gifts. In other words, the school must offer research opportunities 
for such undergraduates as show themselves fitted to do such research. 

"We are too apt to be careless in the use of this term "research." 
Much of the matter which is published from the foreign universities, 
much from our own, is not worth the paper it is written on. It is 
done by immature, poorly trained men, with limited horizon and per- 
spective, and merely encumbers the field for those who come after. 
Real research ability is very rare. It is well to give the practitioner a 
chance to see what research means : that he cannot do research without 



A NEW ERA IN MEDICINE IN NEW YORK 225 

an enormous sacrifice of time, without giving up many of the rewards 
that come to one who has many patients. He cannot obtain much 
more than a living salary — in fact, as a laboratory investigator in 
this country it is difficult to obtain even that. Research in medicine 
is also the most expensive possible research, if we except astronomical 
investigation. It requires not only patients to study, but the facilities 
of large, well-equipped laboratories. The care of patients in New 
York City costs over two dollars a day. This expense must be met 
by the hospitals ; it cannot be added to the already overloaded budget 
of the medical school. 

There is also another function of the medical school, and that is the 
offering to men the opportunity for post-graduate work in various sub- 
jects, chiefly in the specialties, but also in the laboratory branches. 
Most of these men will be practitioners who desire to fit themselves 
for certain special branches, and this instruction must be disassociated, 
more or less, from undergraduate teaching. "With the diminution 
which is now going on in the number of men who take up medicine, 
owing to the overcrowding of the profession, in the first place, and 
owing to the greatly increased cost of medical education in time and 
money — for it means a sacrifice of at least ten years' time to become 
a physician — the number of undergraduate students in the college 
will probably remain small. We do not desire more than one hundred 
to one hundred and twenty-five students in a class. We now have 
about eighty-five. The size of the school is not likely to be increased, 
therefore, in the undergraduate department, in the near future. 
Those who direct the future of the college are desirous of seeing 
extensive development of advanced work and post-graduate teach- 
ing — a great expansion of true investigation along the lines of 
scientific medicine. For this we shall have to have other hos- 
pitals than the Presbyterian; hospitals with ample laboratories, 
with broadly trained clinical teachers in charge of the wards, men 
who can appreciate the problems which are yet to be solved, and of- 
fer the graduate in medicine a chance to develop his special powers 
of clearing away the obscurities which still surround a large number 
of the diseases which we so frequently try to treat. 

The completion of this ideal scheme will probably require a good 
many years of patient labor, and implies, primarily, an extensive 
development of the hospital connections we now enjoy. The final 
solution lies in the hands of the trustees of hospitals, both municipal 
and private, and until they realize what is so obviously needed in 



226 ST. LUKE'S HOSPITAL REPORTS 

medical education, and appreciate the advantages of close union with 
teaching institutions, it is difficult to see how any real progress can 
be made, but there can be no question of the final outcome. The 
hospitals and schools must finally come together to solve their com- 
mon problems and so to obtain their highest possible development, 
from both an educational and a philanthropic standpoint. 



SELECTING LENSES FOR PHOTO-MICROGRAPHY. 
F. C. Wood, M.D. 

The drawing of tissues under the microscope is a difficult matter, 
and but few physicians have the necessary ability or time to produce 
satisfactory sketches. Even professional illustrators are rarely able 
to reproduce such material properly without a great deal of super- 
vision, and then only at considerable cost. On the other hand, the 
production of commercial half-tone plates has now in the best hands 
reached such a degree of perfection that there is but little loss of 
detail in reproducing satisfactory prints of photo-micrographs if made 
on a glossy surface solio or gaslight paper. These facts, together 
with a desire to reproduce microscopic subjects as documents giving 
evidence of the correctness of the text descriptions on which a thesis 
may be based, lie at the bottom of the revival or, if preferred, the 
more extensive use of photo-micrography in illustrating embryological 
and histological publications. 

The recent commercial introduction of color-sensitive plates and 
suitable screens has made possible the use of three-color methods for 
direct reproduction of microscopic objects, if expense of reproduction 
does not have to be considered, in a beauty and accuracy not possible 
in the old days of plate making. The employment of the Lumiere 
direct color plate for projection purposes has also revived interest in 
photo-micrographic methods. 

During the last thirty years the elaboration of the mathematical the- 
ory of the production of images by lenses, due to the genius of E. Abbe, 
and the production of glass of special optical qualities by the Jena 
Glass Works, have also enabled opticians to make many improve- 
ments in lenses. The results have been most notable, perhaps, in the 
production of photographic lenses for general purposes, but very re- 
markable improvements have also been accomplished in the production 
of microscopic lenses and oculars, though chiefly of the higher powers. 

227 



228 ST. LUKE'S HOSPITAL REPORTS 

On the whole, however, these discoveries have not greatly improved 
the objectives of low or medium magnifying power, from a purely 
photo-micrographic point of view. Even in the most admirable 
apochromatic objectives the curvature of the field of vision is often 
very considerable; so much so that the remarkable 8 and 16 mm. 
objectives of Zeiss are not especially satisfactory for photographic 
purposes unless a very small field of view is all that is required. 
"Within such a small field these objectives far surpass almost all lenses 
hitherto constructed, but their chief value lies in visual use rather 
than in photographic work, although the fact that they are apochro- 
matic permits focusing them with white light and afterwards in- 
serting a suitable color screen for photographic purposes without 
danger of altering the focus. With achromatic objectives, on the 
contrary, this is not a very safe process, and generally it is better to 
focus with the light with which the photograph is to be taken, for 
their correction is usually best at about wave length, 550, and is not 
so good with other colors. Fortunately, this is the yellow-green color 
most generally useful in the photo-micrography of ordinary stained 
specimens. 

"With the higher powers, that is, lenses of 4, 3, and 2 mm. focus, 
this curvature of the field is less important, because the actual area 
photographed under any circumstances is very small and the object 
desired is usually a reproduction of fine details rather than a picture 
giving extensive topography. Up to 50 diameters, photo-micrography 
can be admirably done by any one of a considerable series of ob- 
jectives of the photographic type without using an ocular. These 
may be the Zeiss tessars or planars, or the well-known miniature 
photo-objectives of Leitz, "Winkel, or Eeichert. Above this power the 
most satisfactory lens is the micro-luminar of "Winkel of Gottingen, 
of 16 mm. focus. This gives a sharp picture over a 6^ x 8!/^-inch 
plate with a magnification of 75 diameters. "With care, it is possible 
to go a little higher with this objective, but the results are not quite 
so satisfactory. It is, of course, used without an eye-piece, though 
with the special "Complanat" oculars of "Winkel slightly higher 
powers can be obtained with some sacrifice of definition. 

At this point the possibility of computing lenses of the ordinary 
photographic type for use without an ocular ceases, and for higher 
powers we must turn to a form of lens in which the field is never 
perfectly flat, but in which the possible angular aperture, and conse- 
quently the resolving power, rises rapidly with the diminution in 




s 

A. 



Fig. 1 (A). — Giant cell sarcoma of finger, taken with as large an aperture 
as lens will bear, and showing a softer effect more closely resembling images 
seen under the microscope, x 200. 




Fig. 2 (B). — Scirrhus carcinoma. The cone of light is too small; hence, 
the detraction images about the connective tissue. To be compared with A. 



LENSES FOR PHOTO-MICROGRAPHY 229 

focal length. The flatness of the field usually varies inversely with 
the aperture; that is, the higher the aperture the smaller the area 
which is in sharp focus at one time. With the eye this makes but 
little difference, for we are constantly shifting the focus up and down 
and fusing a succession of pictures. As Nelson says: "Curvature 
of image is quite an unimportant error in a microscopic objective be- 
cause all critical observations should be made in the central portion 
of the field, the rest of the field being used merely as a finder. If it 
is necessary to view large masses of an object a lower power should 
be used. Sharp central definition is not always compatible with flat- 
ness of field, and this sharp central definition should never be sacrificed 
for what, at best, is only of small importance." 1 The photographic 
plate, unfortunately, sees only one plane of an object, and there is no 
means of getting other planes into focus ; consequently, it is of the ut- 
most importance to obtain lenses of sufficient angular aperture to give 
all details combined with a field large enough to give topography. 
Usually, extreme apertures should be avoided. Even if the resolution 
of the details of the object over a small area is extremely sharp, it 
must be remembered that the only reason for taking a photograph is 
to produce a print which can be reproduced by a mechanical process. 
In the last analysis, therefore, we should think chiefly of the method 
of reproduction, and there is no need of having excessive detail on a 
plate, because some of the finer points will be inevitably lost in the 
print and much more in the half-tone by which the image is finally 
transferred to paper. Of course, this does not mean that any hazy 
print is sufficient, since the half-tone plate only adds more softness 
and haze to the original, but it does mean that we must consider the 
obtaining of a plate with harsh contrasts of light and shade and with 
moderate sharpness, rather than a thin, exquisitely detailed, smaller 
field, which, excellent as it may be for lantern slides, is totally in- 
adequate for half-tone reproduction. 

The most difficult magnifications to obtain with a sufficient size of 
field to give topographic relations are those extending from about 100 
diameters to 250 diameters. A large proportion of illustrative photo- 
graphs are taken at about this magnification, lower powers than 75 
diameters being employed chiefly for such topographic pictures as are 
wanted for recording lesions of the spinal cord or the distribution of 
glandular elements, such as in the endometrium. These, as has been 

*E. M. Nelson: Jour. Roy. Mic. Soc, 1907, p. 656. 



230 ST. LUKES HOSPITAL REPORTS 

stated, can be taken easily with one of the photographic type of ob- 
jectives. An example of such a photograph of 75 diameters (see 
Fig. 4), taken with the TVinkel nricro-luminar, to show what that lens 
can accomplish, is given. It will be noted that the field is perfectly flat, 
covering a 6^0 x S^-inch plate, with sharp detail to the edges. 

From 100 diameters on, the most usual combination is a 1-inch or 
one-half inch objective. Many firms make two-thirds inch or 16 mm. 
objectives. The older makers in England and America used to pro- 
duce admirable high angle, four-tenths or one-half inch objectives, 
sometimes with correction collar. One of these old achromatic one- 
lialf or four-tenths inch objectives with the correction collar is a real 
prize, which nowadays cannot be frequently picked up. Any one who 
is doing photo-micrography should be on the lookout for such an 
objective. 

The writer, for example, has one such lens, made by Tolles, with a 
focus of four-tenths of an inch and about 0.65 numerical aperture, 
which was discarded as useless by the original owner, who did not 
realize that the lens was corrected, of course, for the tube length in 
general use at the time when the lens was made ; that is, a regular 10- 
inch "English" tube. Consequently, he found that the lens was very 
unsatisfactory when used on a short ' ' Continental ' ' stand. Of course, 
the images are brilliant when used on a proper length tube, and when 
the correction collar is screwed to its highest point the lens works 
splendidly at 160 mm. tube length; the field is very flat, the color 
correction is good. The lenses are as clear as on the day they were 
made, and the whole objective is a testimonial to the magnificent 
work that came from the hands of that great master of lens making. 

It might not be uninteresting to note, in passing, that the writer 
has been offered one hundred dollars for this supposedly worthless 
lens by one who appreciates its optical qualities — a change in value 
almost as remarkable as some stories told of finds of first editions 
of old books. 2 

Such objectives, of course, are not frequently offered for sale at the 
present time, because they are all made for the old long-tube micro- 
scope stands now chiefly used in England, but they can usually be 
obtained for a small sum when they do appear in the stock of second- 
hand dealers. 

'For similar records of a fine old Powell lens made in 1850, N.A. 0.385, 
which is practically equal to a Zeiss 16 mm., N.A. 0.35, see paper by A. A. 
C. Eliot Merlin, Jour. Roy. Mic. Soc., 1907, p. 646. 



LENSES FOR PHOTO-MICROGRAPHY 231 

METHODS OF TESTING LENSES. 

The best method of testing the flatness of field and the optical 
correction of low and medium-power objectives is, not by the eye, 
which continually accommodates to focal differences, but by photo- 
graphing a black and white object with very sharp edges to the black 
lines. The most satisfactory way to obtain an object of sufficient 
fineness and quality is to silver one side of a cover-glass of measured 
thickness and then scratch fine lines through the silver coating. The 
cover-glass is then mounted in balsam, silver side down, and if ex- 
amined will be found to show clear spaces alternating with black 
areas, the edges being perfectly clear cut. Such a grating for testing 
objectives is sold by Zeiss under the name of Abbe test plate. The 
ruling in this case is covered with a wedge-shaped piece of glass, 
from 0.10 to 0.20 mm. in thickness, so that corrections for different 
thicknesses of cover glasses can be obtained if the objective has a 
correction collar. It is not, however, necessary to purchase such a 
special testing apparatus, as one can easily be made as follows : A 
number of cover-glasses of suitable thickness are first obtained. Most 
dealers have measuring calipers and will select a set of cover-glasses 
0.17 to 0.18 mm. thick. This is the usual thickness for which ob- 
jectives are corrected. A series of such cover-glasses should be 
cleaned by moistening them with strong ethyl alcohol, draining off the 
surplus, and then pouring over the cover-glasses a few c.c. of strong 
nitric acid. The beaker should be immediately placed in the open 
air or under a fume hood, as a strong reaction will occur, very of- 
fensive fumes of nitric peroxide being given from the acid. In a 
few minutes, after the boiling of the acid has ceased, the surplus 
should be poured off and the covers rinsed repeatedly in distilled 
water until the water no longer reacts acid to the litmus paper. The 
covers should then be lifted out of the water with clean forceps and 
dried between two layers of filter paper, without touching them with 
the fingers. After blowing off any lint, they should be dropped flat 
on the surface of a silvering mixture so as to float. A convenient 
solution for this purpose is the following: 3 

One gram of silver nitrate is dissolved in 20 c.c. distilled water, 
and strong ammonia (0.880 sp. gr.) is added until the precipitate 
formed is just redissolved. A solution of 1.5 grams potassium hy- 

•Edser and Stansfield. Nature, lvi, 504, 1897. 



232 ST. LUKE'S HOSPITAL REPORTS 

droxide in 40 c.c. water, and again ammonia until the precipitate 
redissolves; 80 c.c. distilled water are next added, and then silver 
nitrate solution (any strength), until there is a faint permanent 
precipitate. Make up to 300 c.c. 

For the reducing solution, 1.8 grams of milk sugar are dissolved 
with the aid of heat in 20 c.c. of distilled water. The two solutions 
are mixed in a flat dish and the cover-glasses immediately dropped 
on the surface of the fluid so that they fall flat and float. The dish 
is covered and left quiet for an hour; at the end of that time, the 
silver deposit is usually thick enough, the covers are lifted out, rinsed 
in distilled water and dried. 

Perfectly satisfactory rulings can be made by taking a fine sewing- 
needle (No. 11), and, making a series of light scratches through the 
silver in various directions, examining from time to time with a 
hand-lens to see that a small area, about 2 or 3 mm., is thoroughly 
scratched up. A more satisfactory preparation, which gives regularly 
spaced rulings, can be made by the use of an ordinary rotating par- 
affin microtome and a microscope with a mechanical stage. A strip 
of stiff spring brass about 25 cm. long, 1 cm. wide, and about 2 mm. 
thick is taken and a fine needle is fastened to the tip with a mass of 
sealing wax. The needle should be perpendicular to the surface of 
the metal. The strip is then clamped to the jaws of the holder ordi- 
narily used for carrying the mounted paraffin blocks for cutting, 
and the feed is adjusted to give any convenient number of microns. 
The most satisfactory spacing is 50 microns, which in the ordinary 
paraffin microtome requires two turns of the wheel. A silvered cover- 
glass is fastened on a slide with some sealing wax, silver side up, and 
clamped to the mechanical stage, and the microscope and microtome 
are clamped to the table so that they do not move in relation to each 
other, and are so arranged that the slide is movable at right angles 
to the line of feed of the microtome. After the preliminary adjust- 
ments have been made, the needle is lowered into contact with the 
silvered surface, the springiness of the brass strip equalizing any 
excess pressure, and a scratch about 10 mm. long is made in the silver 
by moving one of the screws of the mechanical stage. The needle is 
lifted by rotating the microtome slightly and the cover-glass is moved 
out of the way; then the microtome is rotated completely, so as to 
feed the needle forward 50 microns, the point of the needle is again 
brought into contact with the silvered surface, and by moving the 
microtome stage parallel to the first cut and 50 microns from it, an- 




Fig. 4.— N< 



.formal post-menstrual endometrium. Winkel 16-mm. micro- 
luminar, with no eyepiece, x 75. The entire plate is sharp to the edges, but 
as it was impossible to reproduce all. an area 15 x 13 cm. was selected. 



LENSES FOR PHOTO-MICROGRAPHY 233 

other scratch will be made in the silver. This is to be repeated until 
a considerable ruled area is obtained. The slide is then turned at 
right angles to its first position and a series of cross rulings made. 
The cover-glass is then freed from the surface of the slide by softening 
the sealing wax, and mounted in balsam. As soon as the balsam is 
hard, the sealing wax is cleaned off with some strong alcohol and the 
slide examined with a half-inch lens in order to see if the rulings are 
satisfactory. This will usually be so, if a very fine needle has been 
employed. The very finest sewing-needles (No. 11) are the best for 
the purpose. In order to prevent bending, the needle should be set 
a very short distance from its tip, in sealing wax. Not all needles 
have a good point, so before using one, it should be examined with a 
hand magnifying lens or under a low-power objective to see that the 
point is not turned over, as is frequently the case in finer grade 
needles. 

If it is impossible to obtain a ruled test plate as described, an ex- 
cellent object to determine the flatness of field of an objective, though 
not its resolving powers, is a smear of normal blood, or, for short 
focus immersion objectives, a slide of diphtheria or tubercle bacilli, 
thinly spread and faintly stained. The spread of blood should be very 
carefully made, if possible, on a carefully selected plate-glass slide, 
though the ordinary cheap slides will do if one is picked out which 
is flat and free from rough points on the surface. To test the flat- 
ness, hold the slide so as to get a reflection of a window-frame on its 
surface and see whether the lines are straight and do not become 
curved when the slide is rotated. Several slides should be cleaned 
by boiling in strong nitric acid, then washed in distilled water and 
dried with a cloth or filter paper, free from grease. Normal blood 
is then smeared over the surface of the slide, using any of the methods 
regularly employed in preparing specimens for diagnostic work. The 
smears should be thin and perfectly even, and the corpuscles sepa- 
rated from each other by a space equal to about their own diameter. 
The slide is dried and fixed in strong methyl alcohol and stained very 
intensely with a 1/100 solution of water soluble eosin. If desired, the 
leucocytes may be stained after pouring off most of the eosin by the 
addition of a few drops of a 1/400 methylene azure. The blood should 
be then mounted in balsam, using a measured cover. In order to get 
photographs with a satisfactory contrast, it is necessary to use a 
yellow-green screen and a color-sensitive plate, but as this is the light 
which is necessarily used with all achromatic objectives when photo- 



234 ST. LUKE'S HOSPITAL REPORTS 

graphing stained tissues, it does not in the least interfere with the 
test. 

As soon as a suitable mount is obtained, the slide should be set up 
in the microscope, the objective inserted with a suitable projection or 
other eye-piece, and then the lines of the grating or the borders of 
the red cells carefully focused on the ground glass of the camera by 
the use of a hand-lens. It is necessary to see that the condenser is 
in proper adjustment for the lens ; very few lenses will stand a cone 
of light filling more than one-third to one-half of the aperture of 
the back lens. This is best noted by focusing, then removing the eye- 
piece and adjusting the condenser while looking down the tube. If 
a Nernst light, or electric arc, or similar strong source of illumination 
is employed, it is necessary to reduce the intensity of the light by a 
piece of dark glass or a fragment of a photographic dry plate which 
has been exposed to daylight for a second and then developed and 
fixed. This will usually give a neutral tint film sufficiently opaque 
to prevent injury to the eye. "With a Zeiss photographic apparatus 
such a dark glass is provided in a cap which fits into the end of the 
draw tube. If the photographer is fortunate enough to possess one of 
the old-fashioned four-tenths or one-half inch achromatic objectives 
made by Powell & Lealand, Tolles, H. R. Spencer, or "Wales, which 
are provided with a correction collar, great care should be taken in 
seeing that this collar is turned until the best correction is obtained 
for spherical and chromatic aberration. The colored fringes seen at 
the edge of the black lines are present, to some extent, with all achro- 
matic objectives, especially at the periphery of the field, and their 
complete removal, except at the center, is not so important as the 
perfect correction of the spherical aberration, as is shown by the 
perfect sharpness of the edges of the silver bands or the blood cells. 
Most objectives are now corrected for a shorter tube length, usually 
either 160 or 170 mm., and marked, as a rule, with the proper length 
for the draw tube. It is necessary, if the objective is not screwed 
directly into the nose-piece, to allow for either 10 mm., in case of a 
revolving nose-piece, or 22 mm., in the case of the Zeiss sliding ob- 
jective changers. The old-fashioned achromatic objectives with cor- 
rection collar, even when computed for the long tube, often work 
admirably on the modern short tube-stand if there is a sufficient 
range of collar adjustment. 

As it is not always easy to judge the point at which definition be- 
gins to fall off, it is usually better to make a photograph rather than 



oe 



08 



09 



.0 



07 0.7 



0.8 0.8 



1.2 



1.3 



T 

.1.8 



0.9 0.9 



1.0 



,2 



I 1.3 



Fig. 5. — I. Tolles % inch, showing sharp Held over 
0.0 mm. x 200. 
II. Tolles 4-10 inch, showing sharp field over 
0.7 mm. 
III. Spencer 1 inch, eomplanat eyepiece No. 1. 
showing sharp field over nearly 0.!) mm. 



.2 



.3 



4 



in 



LENSES FOR PHOTO-MICROGRAPHY 235 

to rely entirely upon the eye. The most suitable plate for this pur- 
pose is the Cramer isochromatie double-coated plate, which has great 
latitude of exposure and stands prolonged development without fog- 
ging, and yet is sensitive to the yellow-green color used in tissue 
photography. 4 The exposure should be short and the development 
prolonged in order to bring up all possible contrast. When the nega- 
tive is dry a print can be made from it if desired, and the quality of 
the image judged from the print, but to any one who is experienced 
in looking at negatives, it will be easy to determine the approximate 
point at which the sharpness of image ceases, and that, of course, is 
the size of the useful field of the objective. It is generally somewhat 
easier to tell the exact point from a blood smear photograph than it is 
from the photograph of the ruled screen. The screen, however, af- 
fords a better test of the optical qualities of the objective than the 
corpuscles, because the edges of the silver bands are extremely sharp 
and the slightest haziness or color is shown in the photograph as a 
lack of sharpness to the edge. Another definite way of getting the 
diameter of the field, though it is not a satisfactory one for the re- 
solving power of the objective, is to photograph a stage micrometer.- 
If the lines are black or the micrometer used is one of the photo- 
graphic reproductions, the diameter of the useful field can be fairly 
easily told ; but, as just stated, it is not a satisfactory test for resolu- 
tion, because by varying the time of exposure, the screen and the de- 
velopment, the apparent sharpness of the lines can be varied and a 
poor objective will give, on a thoroughly developed plate, a much 
better picture than a good objective on a thin plate. 

In order to get the best definition the lens should be used with an 
achromatic condenser of approximately the same focus as the ob- 
jective. If such a condenser is not available, a lens of about the 
same aperture and focus can be used in the substage as a condenser 
with the most satisfactory results. On looking down the tube of the 
microscope, the illuminated area of the condenser diaphragm should 
be central, and the maximum amount of light used which the objective 
will bear without the image becoming hazy. If the light is not cen- 
tered or if the diaphragm is reduced to too low a point, the diffraction 
lines will appear at the borders of the red corpuscles or at the edges 
of the rulings of the Abbe test plate. It is, unfortunately, only too 

4 It is not necessary to go into further details concerning plates or de- 
veloper here ; possibly in a subsequent number of this report the subject of 
plates, screens, developers, etc., will be fully treated. 



236 ST. LUKE'S HOSPITAL REPORTS 

common to see photo-micrographs in which the diameter of the sharp 
field of the objective has been increased by the process of reducing 
the cone of light thrown by the condenser to a very small diameter. 
The result is that, while the field covered by the objective is slightly 
larger, diffraction lines are present about the borders of the nuclei, 
and the bodies of the cells and all finer details are lost. The ad- 
vantage of the use of lenses of large aperture is that they stand a 
good deal of light without the image becoming hazy, and therefore 
the exposure may be shortened with equal or better definition. In- 
fluenced, perhaps, by the constant habit of looking at or making 
drawings of histological material with a pen, the average person 
thinks that a photo-micrograph showing diffraction lines represents 
more accurately the appearances usually present under the micro- 
scope than a much softer picture obtained by the use of a high-angle 
immersion lens, but a little study of stained sections under the micro- 
scope with high-grade lenses and a suitable condenser and light will 
show that, on the contrary, few cells have a sharp outline, and that in 
well preserved material each shades into the next contiguous cell 
without any great contrast. The routine fixation and hasty paraffin 
embedding of much of the material ordinarily examined has also con- 
tributed not a little to the sharp outline attitude, for the inevitable 
shrinkage following such procedures tends to isolate cells or groups 
of cells and thus leave clear spaces about them. 

AREA OF USEFUL FIELD. 

The results of the examination of photographs of ruled silvered 
plates, of blood slides, and of stage micrometers is shown in the ap- 
pended table. The magnification chosen was a constant one ; that is, 
200 diameters, this being the maximum magnification likely to be used 
with medium power objectives; above that point, 6 or 4 mm. lenses 
are to be preferred, though an exceptional 8, 10, or 12 mm. lens 
may permit a useful magnification of 250 to 300. This is much 
lower than the theoretical "useful magnification," which is usually 
given as 100 times the numerical aperture; in other words, a lens of 
N.A. 0.20 should give a good image at 200 diameters, one of 0.30 at 
300 diameters, one of 0.65 at 650 diameters; but in practice but few 
objectives will give more than half this, and the ordinary cheap 
commercial achromats not more than a third or even a fourth. The 
test is therefore much more severe on the 16 to 25 mm. lenses than 
on those of shorter focus. Possibly all that can be expected of inch 




Fig. 6. — Zeiss s-inm. apochroniat, with No. '■> pro- 
jection eyepiece, x 200. The ink ring shows the 
limit of the sharp field. 



LENSES FOR PHOTO-MICROGRAPHY 237 

objectives is a maximum of 125 to 150. A few lenses, even though 
their aperture is relatively low, will give good pictures at 200 di- 
ameters, the best example the writer has seen being the Winkel apo- 
chromat of 25 mm. focus with a N.A. of 0.22. This exceptional lens 
stands 200 diameters better than many of much shorter focus and 
larger aperture, with a sharp field covering a 6y 2 x 8y 2 plate. 

The objectives, concerning which further details are given in Table 
II, fall naturally into two groups ; the first 8 of 12 mm. or less in focus, 
the last 5 of between 16 and 25 mm. focus. Of the half-inch lenses, 
the Tolles one-half is the superior though its low aperture of 0.42 
requires more careful handling of the illumination than the three 
which follow. The Spencer Lens Company's 8 mm. apochromat is 
one of the best for photography now being made. The Watson lens 
is only fair. The Powell and Lealand, though still made, is not to be 
recommended. The particular type of Bausch and Lomb half-inch 
is no longer listed by that firm, but is a very fine lens. Last of all 
comes the 8 mm. Zeiss, with so small a field that its usefulness is 
much restricted, though within that field it gives the best and sharp- 
est images of any objective examined. In the second group, the 
maker of the Spencer lens is long since dead, but the lens is a re- 
markable one. Close to it is the Winkel apochromat, which is the 
best lens now obtainable for low-power photography ; that is, between 
75 and 200 diameters. The Zeiss and Leitz 16 mm. are very good for 
within the sharp field, but this is much too limited for photographic 
purposes. 

A long series of tests have also been made with low-power achro- 
matic lenses of both foreign and domestic makers, but though, with 
patience and great care, fair results can be obtained, they are not 
wholly satisfactory. The optical requirements for photographic work 
are much more severe than for purely visual effects, for which these 
lenses are intended. In the higher powers, however, some excellent 
lenses are obtainable, especially the "flourite" objectives of Leitz and 
Reichert, but better work can be done with the 4 and 6 mm. dry 
apochromats of Zeiss, and still better with Powell and Lealand 's 
quarter-inch apochromatic immersion. For the highest magnifications, 
such as are required for photographing bacteria, the improved achro- 
matic 1/12-inch oil immersions are very satisfactory, though nothing 
quite equals the Zeiss 3 mm., N.A. 1.40. 



238 



ST. LUKE'S HOSPITAL REPORTS 



I.— TABLE OF LENSES ARRANGED ACCORDING TO DIAMETER OF USEFUL 
FLAT FIELD AT A MAGNIFICATION OF 200 DIAMETERS. 

of Field in Millimeters with Zeiss II. Projec- 
Lens tion Eye-piece 

Tolles % inch. 110 mm. Definition satisfactory. 

o«^ii 4, •„ », (100 mm. Used with 160 mm. tube. 

/"> 1D 85 mm. Used with 250 mm. tube. Definition about the 

same, but better than the % inch. 
Wales 4 / 10 inch. 
Powell and Lealand % inch 

achromatic immersion. 
Spencer Lens Co. 8 mm. apo- 

chromat. 
Watson % inch holostigmat. 
Powell and Lealand % inch 

apochromat 160 mm. tube. 
Bausch and Lomb % inch, 

Series III. 
Zeiss 8 mm. apochromat. 

Leitz 8 mm. apochromat. 

H. R. Spencer 1 inch 250 mm. 

tube. 
Winkel 25 mm. apochromat. 

Zeiss 17 mm. achromat AA. 
Watson 24 mm. 

Zeiss 16 mm. apochromat. 
Leitz 16 mm. apochromat. 



Diameter 


110 
100 

85 


mm. 
mm. 
mm. 


90 


mm. 


90 


mm. 


75 
70 
75 


mm. 
mm. 
mm. 


60 
60 


mm. 
mm. 


60 


mm. 


115 


mm. 


160 


mm. 


180 
170 


mm. 
mm. 


70 
75 


mm. 
mm. 



Very good definition. 

Fair definition ; much better than would be 
expected from resolution tests. 

Very good definition. 

Definition better over this area than any of the 

above lenses, except the immersion P. & L. 
Definition even better than the Zeiss in the lens 

examined, but not equal to the immersion. 
With Winkel Complanat Eye-piece No. 1 field 

is 200 mm., with excellent definition. 
With Complanat Eye-piece No. 2, 180 mm. and 

very good definition. 
Very fair definition. 
Field, but very poor definition all over ; will 

not give good picture at over 150 diameters. 
Good definition. 
Good definition. 



II. — TABLE OF RESOLUTIONS OF SERIES OF LENSES. 

The diatoms employed were Nitschia scalaris (abbreviated N.S.), 26,000 lines to the 

inch, mounted in styrax, and Pleurosigma angulatum (abbreviated P. A), 

44,000 lines to the inch, mounted in realgar. 



Grade Lens 

100 Tolles achromatic 4 /io inch or 

10 mm. N.A.=0.65 for 250 

mm. tube. 
100 Zeiss or Leitz 8 mm. apochro- 

matic. N.A.=0.65 for 160 

mm. tube. 
90 Wales achromatic Vio incn or 

10 mm. N.A.=0.60 for 160 

mm. tube. 
75 Spencer Lens Co. 8 mm. apo- 

chromatic. N. A. =0.60 for 

160 mm. tube. 
70 Watson holostigmat 12 mm. 

N.A.=0.45 for 170 mm. 

tube. 
70 Bausch and Lomb, Series III, 

12 mm. N.A.=0.54 for 210 

mm. tube. 
65 Tolles % inch. N.A.=0.42 for 

250 mm. tube achromat. 

65 Powell and Lealand % inch 
or 12 mm. apochromatic. 
N.A.=0.64 for 250 mm. tube. 

60 Herbert R. Spencer 1 inch or 
25 mm. N.A.=0.35 achro- 
mat. 

60 Zeiss 16 mm. N.A.=0.30 apo- 
chromatic for 160 mm. tube. 

50 Zeiss 17 mm. A. A. achromat. 
N.A.=0.30. 

45 Watson 24 mm. N.A.=0.24 
holostigmat. 

45 Winkel 25 mm. N.A.=0.22 
apochromat. 





Resolution Central 


Resolution Oblique 


Objecl 


Light 


Light 


N.S. 


Easily into dots, even 


Very easily into 




better than Zeiss 8 mm. 


dots. 


P.A. 


Easily into dots. 


Easily into dots. 


N.S. 


Easily into dots. 


Easily into dots. 


P.A. 


Easily into dots. 


Easily into dots. 


N.S. 


Dots. 


Dots. 


P.A. 


Easily into dots. 


Easily into dots. 


N.S. 


Dots. 


Dots poorly. 


P.A. 


Dots. 


Dots. 


N.S. 


Good resolution, but 
only lines. 


Fairly into dots. 


P.A. 


Not resolved. 


Fairly into dots. 


N.S. 


Fairly into lines. 


Fairly into dots. 


P.A. 


Fairly into dots. 


Fairly into dots. 


N.S. 


Easily into lines. 


Fairly into dots. 


P.A. 


Not resolved. 


Poor resolution in 
dots. 


N.S. 


Lines only. 


Dots poorly. 


P.A. 


Not resolved. 


Not resolved. 


N.S. 


Lines only. 


Lines only. 


P.A. 


Not resolved. 


Not resolved. 


N.S. 


Lines only. 


Lines only. 


P.A. 


Not resolved. 


Not resolved. 


N.S. 


Lines only. 


Lines only. 


P.A. 


Not resolved. 


Not resolved. 


N.S. 


Just shows lines. 


Just shows lines. 


P.A. 


Not resolved. 


Not resolved. 


N.S. 


Barely shows lines. 


Barely shows lines. 


P.A. 


Not resolved. 


Not resolved. 



SWv ^A* \? . *. .v 




Fig. r. — Powell and Lealand ^-inch apochromat x 200. The ink ring 
shows the limit of the sharp field. 



LENSES FOR PHOTO-MICROGRAPHY 239 

The resolution, or ability to reproduce fine details, also varies di- 
rectly with the numerical aperture of the lens, but a lens of high aper- 
ture may not be so satisfactory as one of slightly smaller opening if 
its spherical and chromatic corrections are not also perfect. 

An example of this is seen in the Powell and Lealand half-inch 
apochromatic, which will be discussed later. Theoretically, this lens 
should be an excellent one, but practically it is worthless. 

Resolution being equal, the best lens in every respect is the one 
giving the largest field. With the low powers it is possible that the 
entire field may not be employed for reproduction, but it is very con- 
venient to have a little leeway so that the exact centering of the 
image to be obtained is not necessarily carried out under the micro- 
scope, but a general field selected from which a suitable part may be 
cut for final use as an illustration. The selecting and absolute center- 
ing of an exact field on the ground glass of the camera focus is time- 
consuming, and it is difficult, without a great deal of experience, to 
judge the final effect of a tissue photograph, either in the camera or 
from a negative; the print is the best criterion. 

The most accurate means of testing the resolution alone, because 
the mere marking of the angular aperture on the objective does not 
guarantee that the measurement is correct, is to use a diatom, suitably 
mounted. The objectives under consideration range from 25 to 8 mm., 
with a numerical aperture of from 0.22 to 0.65. There are two di- 
atoms which offer convenient standards. These are the Pleurosigma 
angulatum and the Nitschia scalaris. They should be mounted in a 
highly refracting medium, such as realgar, or, if such preparations 
cannot be obtained, dry. The light used must be intense ; direct sun- 
light, if properly screened, is good ; or the direct light from a Nernst 
filament or miniature arc lamp, or even a flat-wick kerosene lamp is 
preferable to daylight. The condenser must focus the light on the 
object. Under such conditions it is remarkable what a good lens will 
do. For instance, the writer has been able to resolve Amphipleura 
pellucida in realgar with the Zeiss 4 mm. short-tube apochromatic 
lens and a dry Watson parachromatic condenser, using a suitable blue 
screen. Usually, nothing but an immersion lens will show the lines 
on this most difficult object. 

The table on page 238 shows the results of the examination of a 
series of lenses in the possession of the writer — a rough estimate in 
percentage is given to aid in classification, but has no claim to ac- 
curacy. It will be seen that the resolution of Pleurosigma in dots by 



240 ST. LUKE'S HOSPITAL REPORTS 

central light immediately divides the objectives into two classes, those 
above N.A. 0.50 and those below, though a Powell and Lealand one- 
half N.A. 0.64, falls, for some unknown reason, into the lower class. 
The Nitschia scalaris gives another dividing line when resolved into 
dots by oblique light at N.A. 0.40. All of the objectives thus tested re- 
spond pretty closely to the theoretical limits, those usually set being 
a numerical aperture of at least 0.65 for the resolution of the dots 
of P. angulatum with an axial light, slightly less for lines, and at 
least 0.30 for N. scalaris in styrax; the only exception being the 
Powell and Lealand half-inch, N.A. 0.64, which falls way below its 
class, being surpassed by the Watson and Bausch and Lomb half -inch 
objectives of considerably lower aperture and equalled by a Tolles 
half-inch achromatic, N.A. 0.42. The flat field of this lens is almost 
twice that of the Powell and Lealand, and for photographic work the 
objective is much superior, though made some 40 years ago, before 
the discovery of the Jena glasses and the computations of Abbe, per- 
mitting apochromatic lens construction. 

In the same way the Tolles 4/10-inch is equal to, and possibly 
surpasses in resolving power, the best modern product of Zeiss, the 
8 mm. apochromat, while its field is much larger. Close behind is an 
old achromatic 4/10-ineh Wales, with slightly lower aperture, but 
with a large, flat field and exquisite definition. Either of these old 
lenses are much superior to the modern achromatic lenses of any 
maker for the purposes of photography, if we except a Powell and 
Lealand half-inch immersion, specially made for the writer, with a 
numerical aperture of 1.30. This has a flat field of 90 mm. and gives 
better definition and greater resolution than any dry lens. It is, 
however, purely a photographic objective, and not useful for other 
purposes. 

Some improvement in the flattening of the field can no doubt be 
obtained by improvement in the eye-pieces employed in photographic 
work. A step in this direction has been taken by Winkel, whose so- 
called "complanat" eye-piece gives a somewhat flatter field with his 
objectives than with the projection type of eye-piece made by Zeiss, 
and, in fact, the performance of the old achromatic objectives is often 
better with a complanat than with a projection eye-piece. 

CONCLUSIONS. 

A complete outfit of lenses suitable for the highest class of photo- 
micrography is expensive, and, though fair results can be obtained by 



LENSES FOR PHOTO-MICROGRAPHY 241 

the use of the cheaper grades of achromatic lenses generally fitted to 
microscopes, quite satisfactory for ordinary visual work as they may 
be, yet good photographs can only be made with the finest lenses, for 
defects which the eye will entirely overlook will become most apparent 
when a lens is used for photography. An ideal outfit would be the 
following : 

1. Zeiss planar 75 mm. focus for very low powers. 

2. Winkel micro-luminar, 16 mm. focus, for magnification from 25 to 75 
diameters. 

3. Winkel 25 mm. apochromat with complanat eye-pieces I and II, for 
75 to 150 diameters. 

4. Tolles, Spencer, or Wales 7 10 or y 2 -inch for from 150 to 200 diameters. 
In lieu of these a Spencer Lens Company's 8 mm. apochromat is the best 
now on the market as regards flatness of field. The Zeiss or Leitz 8 mm. 
apochromat is more expensive and has a smaller field, though giving su- 
perior definition. 

5. A Powell and Lealand %-inch apochromatic immersion, N.A. 1.30, for 
200 to 500 diameters. As this lens is expensive, a dry apochromat 4 or 6 mm. 
of Zeiss, or any other standard make, such as Winkel, Leitz, or Reichert, 
may be substituted, but the flat field is smaller than in the immersion and 
the lenses more difficult to handle because of the necessity for careful ad- 
justment of the light and their sensitiveness to varying thicknesses of cover- 
glass. The Powell and Lealand immersion is the most satisfactory lens made 
for medium powers. 

6. A Zeiss 3 mm. apochromat, N.A. 1.40, for the long tube. This is one 
of the most remarkable lenses made. It gives a range of from 500 to 1,400 
diameters with the Zeiss III and VI projection eye-pieces, which are also 
to be employed with lenses IV and V. It is less easily injured than the 2 
mm. Zeiss apochromat, N.A. 1.40, the front lens of which may be dismounted 
by the slightest touch to a cover-glass, and has a larger field. The long 
tube, 3 mm., is a shade better than the short tube lens of the same aperture 
and focus. In fact, all of the long tube objectives give better results than 
the short tube ones, as the same magnification can be obtained with a lower 
eye-piece. 



CASE OF INCOMPLETE RUPTURE OF THE HEART DUE TO 
CORONARY HEMORRHAGE. 

J. Gardner Hopkins, M.D. 

The patient was a woman of fifty years, a designer by occupation. 
Except for the diseases of childhood, she had always been well up to 
four days before admission to the hospital, when she was suddenly 
seized with a feeling of suffocation while at work and had to be taken 
home. This attack was followed by rather severe constant pain in the 
precordium, which increased on deep breathing. She had no other 
symptoms. As the pain continued, she came to the hospital and was 
admitted on Dr. Janeway's service. On examination, the apex beat 
was not made out. The heart dulness was apparently increased ; the 
sounds were distant but normal ; no murmurs were heard. . The pulse 
was regular and of good force. After rest in bed, the pain disap- 
peared, and on the third day the patient was allowed to sit up, with 
the expectation of discharge in a few days. While being wheeled to 
her bed after defecation, she became deeply cyanotic, fell forward 
in her chair, and apparently died instantly. 

At autopsy, the pericardium contained coagulated blood which 
formed a thick layer about the anterior, posterior, and right surfaces 
of the ventricles and extended up about the aorta and pulmonary 
artery. The clot was thickest at the apex posteriorly, where it meas- 
ured 2.5 cm. The ventricles and right auricle were in systole and 
left auricle in diastole (Fig. 1). The leaflets of all the valves were 
thickened and those of the mitral showed atheromatous plaques. 
There was no evidence of endocarditis. In the apex of the left ven- 
tricle was a blood clot about 2 cm. in diameter, and in the anterior 
wall near the septum was a cleft filled with blood clot continuous with 
that in the ventricle (Fig. 2). This cleft extended downward and to 
the left, following the course of the muscle fibers. At the left border 
of the heart it reached the subpericardial fat and extended through 
the fat, communicating with the pericardium apparently at the apex 
posteriorly, though the precise point of communication was not made 

242 



RIGHT AURICLE 




LETT AURICLE 



PULMONARY ARTERY 



AORTA 



Fig. 1. — Section through base of heart, viewed from above, showing compres- 
sion of right auricle and dilatation of left auricle. 




B 
8 

< 

a 
s 



O 
•J 

o 

§ 

o 

►J 
m 



APEX OF LEFT VENTRICLE 



RUPTURE 



Fig. 2. — Section through heart, near apex, viewed from below, showing 

rupture in the wall. 



INCOMPLETE RUPTURE OF THE HEART 243 

out. There was also hemorrhage in the fat below and about the apex 
of the right ventricle. The blood clot in the ventricle was covered 
by a delicate membrane, which, on section, consisted of a fibro-cellular 
membrane covered with endothelium, and was evidently the remains 
of the endocardium, showing that the blood had lain beneath the 
endocardium and not actually in the ventricular cavity. The coro- 
naries showed extensive sclerosis, and the descending branch of the 
left coronary was much thickened and diffusely calcareous. The ex- 
ternal diameter of this vessel was about 4 mm., but its lumen was 
very small. About 4 cm. from its origin the lumen was practically 
occluded by the thickening ; but could be traced, on section, 1 cm. or 
more below this point (Fig. 3). The anterior wall of the left ven- 
tricle in the region supplied by this artery was pale yellow and glisten- 
ing and translucent on section. There were other smaller tears in the 
muscle, also filled with thrombi, which did not extend to the pericar- 
dium. Microscopically, the muscle cells in this area were shrunken 
and hyaline in appearance. In some areas they showed no nuclei ; in 
others they had small, deeply staining nuclei. Between the necrotic 
cells there were rows of polymorphonuclear leucocytes, among which 
were a few small, round cells. In places the leucocytes were collected 
in masses resembling small abscesses (Fig. 4), in which a few partly 
calcified fragments of muscle cells could be seen. No bacteria were 
seen in these areas. There were also many leucocytes about the tears 
in the muscular wall. The small arteries in the wall were thickened 
and some were filled with organized thrombi (Fig. 5). The pericar- 
dium was thickened, due chiefly to infiltration with small round cells 
and large cells of endothelial type. 

The aorta showed extensive arteriosclerosis with calcification, and 
there was marked interstitial nephritis. 

The anatomical diagnosis was: Arteriosclerosis of aorta and coro- 
nary arteries. Myomalacia of anterior wall of left ventricle. Incom- 
plete rupture of the heart due to hemorrhage from a coronary vessel. 
Hemopericardium. Chronic interstitial nephritis. Adenoma of renal 
cortex. Chronic passive congestion and fatty degeneration of liver. 
Emphysema, congestion, edema, and healed tuberculosis of lungs. 

Rupture of the heart is among the rarer causes of sudden death 
and has aroused much interest since the first case described by Har- 
vey. Morgagni described a number of cases from his own experience, 
but the lesion appears to be much less frequent in recent times. El- 
leaume collected sixty-one cases, thirty-seven of which were in men 



244 ST. LUKE'S HOSPITAL REPORTS 

and twenty-four in women. The rupture is usually very minute, as 
in this case, and usually larger externally than internally. The cleft, 
as a rule, follows the course of the muscle fibers. Occasionally there 
is a long tear, in one case from the base to the apex ; and from three 
to five multiple tears have been reported. Forty-three of fifty-five 
cases involved the left ventricle, and the usual point is in the an- 
terior wall, near the apex. The rupture may follow embolic or 
sclerotic occlusion of the coronary artery with subsequent softening 
of the wall. Abscesses in the myocardium, gummata, and tumors have 
also led to rupture. Ten of Elleaume's cases were due to rupture of 
an aneurism of the heart, which is a relatively frequent cause. Quain 
suggested that diffuse fatty change might lead to rupture, but this 
seems unlikely as it lessens the force of the heart action and would 
rather tend to prevent rupture. 

Rupture of the heart occurs in old age and usually after severe 
exertion. It sometimes occurs without any apparent occasion, and 
even while the patient is asleep. In other cases it may follow psy- 
chical excitement, as in the case of Philip the Second of Spain, who 
died of rupture of the heart when told of the defeat of his armies. 

In the case reported here, rupture was evidently due to degenera- 
tion of the myocardium in the region supplied by the descending 
branch of the right coronary artery. The sections of the heart muscle 
present a typical picture of acute suppurative myocarditis, but the 
history of the case is very much against the supposition that the 
process was infectious. There was no evidence of endocarditis and 
pericarditis, or any other condition which would account for the origin 
of an infectious myocarditis. It is probable that the collections of 
leucocytes were not due to bacterial infection, but to reaction about 
the necrotic tissue. These collections of leucocytes are commonly 
found in softening of the myocardium. The fact that the inner 
blood clot lay beneath apparently intact endocardium makes it seem 
probable that the rupture was due to hemorrhage from some coro- 
nary vessel which penetrated internally beneath the endocardium 
and externally into the pericardial sac. There was no escape 
of blood from the ventricle. From the amount of reaction about the 
clot, the first hemorrhage into the wall probably occurred when the 
patient had the first attack of dyspnea, and the terminal event was 
rupture of this intramural hematoma into the pericardium. 

The most interesting feature of the ease is the condition of the 
auricles. In a section through the base of the heart (Fig. 1) the left 



.-/?*:*-.. 







,>.. 






1 

■ 

Fig. 3. — Photomicrograph showing cross section of the descending branch 
of the left coronary artery. The lumen is obliterated, except for two narrow 
slits at the right. To the left is a calcified area. 20 diameters. 



^*&3>Zt\\ ■&**£■ -.it- 




§1 : 'ftSlliHiiil 

iii: ill 




/■ 






Fig. 4. — Photomicrograph showing collection of leucocytes in necrotic heart 

muscle. 45 diameters. 




Fig. 



-Photomicrograph showing remains of endocardium covering the blood 
clot in the ventricle. 22."> diameters. 







Fig. 6. — Photomicrograph of the necrotic heart muscle, showing small throm- 
bosed vessel, surrounded by leucocytes. 200 diameters. 



INCOMPLETE RUPTURE OF THE HEART 245 

auricle is seen to be in diastole, while the right auricle is compressed 
to a mere slit. This illustrates clearly the theory of Cohnheim that 
death in hemopericardium is due to compression of the right auricle, 
the chamber in which the blood pressure is the lowest. He injected 
fluid into the pericardial sacs of dogs and showed that the sudden in- 
jection of 150 c.c. to 200 c.c. was sufficient to cause death, whereas, 
a much larger amount of fluid might accumulate gradually in the 
pericardium without a fatal result. The effect depends upon the 
tension of the fluid rather than upon its amount. As the pericardial 
pressure approaches the pressure in the right auricle it interferes with 
the entry of the blood into the heart from the systemic veins, causing 
a rise in venous pressure and a fall in arterial pressure. The pres- 
sure in the left auricle is considerably greater than in the right, and 
consequently the entry of blood from the lungs is not interfered with 
until the pericardial pressure is increased considerably above the point 
necessary to compress the right auricle. 

References. — Cohnheim, Allegemeine Pathologie. Trans, by McKee, vol. i» 
p. 30. Elleaume, Essai sur les ruptures de cceur. These de Paris, 1857. Fried- 
reich, Virchow's Handbuch f. spezielle Pathologie u. Therapie, vol. v, sec. 2, 
p. 183. Morgagni, De sedibus et causis morborum, book ii, letter 27. Quain, 
Medical and Chirurgical Transactions, London, vol. xxxiii. 



REPORT OF THE WASSERMANN REACTIONS DONE BY THE 
PATHOLOGICAL DEPARTMENT DURING THE YEAR 1911.* 

C. H. Bailey, M.D. 

During the past year 597 "Wassermann reactions have been done 
by the Pathological Department. The results of the reaction on the 
423 cases whose histories were accessible were as shown in the fol- 
lowing table: 



Positive 
Syphilis : 

Primary 6 

Secondary, untreated 20 

Secondary, treated 7 

Tertiary 54 

Latent 24 

Congenital 2 

General paresis 1 

Tabes 5 

Diseases possibly of syphilitic origin : 

Aneurism 6 

Aortic insufficiency 9 

Facial paralysis 1 

Chronic inflammations of the eye 7 

Diseases not diagnosed clinically as 

syphilitic 1 2 3 177 

Those cases are classed as positive which gave complete inhibition 
in the tube containing 0.2 c.c. of the patient's serum and antigen, with 
complete hemolysis in the control tube containing 0.4 c.c. of the pa- 
tient's serum without antigen. Those in which there was a slight 
trace of hemolysis in the tube with antigen and complete hemolysis 
in the control, and those which, with complete inhibition in the tube 
with antigen, showed a trace of inhibition in the control, are classed 
as doubtful positive. Those with partial hemolysis with antigen or 

*A portion of this article appeared in the Archives of Internal Medicine, 
May, 1912. 

246 



Doubtful 


Doubtful 




positive 


negative 


Negative 


1 





1 








1 





1 


4 


11 


1 


10 


9 


1 


26 


1 





2 











2 


1 


2 


2 














5 








2 


2 





13 



REPORT OF WASSERMANN REACTIONS 247 

partial inhibition in the control are classed as doubtful negative; all 
others as negative. 

The three cases classed under "Diseases not diagnosed clinically 
as syphilitic" which gave positive or doubtful positive reactions re- 
quire special mention. 

Rheumatoid Arthritis. — Wassermann positive. No history of syphilis ob- 
tainable. Patient complained of pain and swelling in her right great toe of 
three weeks' duration. Pain in right ankle and left arm for one week. On 
entrance, toe was swollen, somewhat red, and tender. Slight tenderness over 
inner aspect of left tibia. Temperature normal. During her five weeks in 
hospital both elbows and several phalangeal joints were involved. Patient 
was on mixed treatment eleven days, potassium iodide being continued nine- 
teen days longer, without improvement. 

Gelatinous Carcinoma of Rectum. — Wassermann doubtful positive. The 
patient denied lues, and the past history was not suggestive. Diagnosis was 
made from section of excised portion of tumor. 

Lymphosarcoma of Tonsil. — Wassermann doubtful positive. This woman 
gave a history of one miscarriage, one child born dead at term, one child dead 
at 22 months (cause not known). She had two living children. Otherwise, 
there was nothing suggestive in the past history. Diagnosis was made from 
section of excised portion of tumor. 

The cases on which Wassermann reactions have been done subse- 
quent to the injection of Ehrlich's 606 are but fourteen in number. 
These cases are, however, of sufficient interest to report individually. 

Case 1. — Oct. 25, 1910. Chancre of lip. Spirocheta pallida present. Wasser- 
mann positive. 
Intramuscular injection of 0.6 gm. 606. 
Roseola present. 

Intramuscular injection of 0.6 gm. 606. 
Spirocheta pallida present. Wassermann positive. 
Wassermann positive. 
Wassermann positive. 
1, 1911. Wassermann positive. 
Case 2. — Primary lesion six years ago. Came in for stricture of urethra, one 
month duration. 
July 1, 1911. Intravenous injection 606. 
July 12. Wassermann negative. 

Case 3. — Primary lesion four months previously, followed by secondaries. 
Dec. 4, 1910. Intramuscular injection 0.5 gm. 606. 
Jan. 4, 1911. Wassermann positive. 
Case 4. — Secondaries in February, 1911. Then six months pregnant. 

Mar. 8, 1911. Wassermann positive. Intramuscular injection of 

606, followed by mixed treatment. 
June 28. Wassermann negative. Baby said to be well. 



Oct. 


26. 


Nov. 


8. 


Nov. 


15. 


Nov. 


19. 


Dec. 


7. 


Dec. 


21. 


Feb. 


1, 



248 



ST. LUKE'S HOSPITAL REPORTS 



Case 5. — Primary lesion April, 1910. Secondaries about one month later. 
From August up to the time of admission to hospital had numer- 
ous ulcerating lesions on various parts of body. Treated continu- 
ously, since primary lesion, with mercury, by inunction and injec- 
tion, without effect. 

Nov. 26, 1910. Entered hospital. Condition : multiple gummata and 
serpiginous syphilides. Wassermann positive. 

Nov. 27. Intramuscular injection of 0.4 gm. 606. 

Jan. 4, 1911. Wassermann positive. Lesions healing rapidly. 

Apr. 26. Wassermann negative. Lesions healed. 

Case 6. — Infant, age two months. 
Oct. 16. 



Oct. 18. 

Oct. 25. 

Nov. 2. 

Case 7. — June 7, 

June 10. 
June 24. 
June 26. 
July 29. 
Aug. 30. 
Nov. 15. 



General eruption, snuffles, hoarseness. Large liver 
and spleen. Wassermann positive. 0.025 gm. 
606 administered subcutaneously. 
Wassermann positive. 
Wassermann positive. 

Wassermann positive. Condition much improved. 
1911. Fading roseola, and mucous patches. Wassermann 
positive. 
0.6 gm. 606 intravenously. 
0.6 gm. 606 intravenously. 
Wassermann positive. 
0.6 gm. 606 intravenously. 
Wassermann positive. 
Wassermann positive. 
Has had no symptoms since first injection. 
Case 8. — Jan. — , 1910. Primary lesion, followed by secondaries. Treated 

with mercury. 
Sept. 15, 1911. Wassermann positive. Has no symptoms. 
Sept. 22. 0.5 gm. 606 intravenously. 

Oct. 17. Wassermann positive. 

27. 0.5 gm. 606 intravenously. 

28. Wassermann doubtful positive. 
7. 0.6 gm. 606 intravenously. 

27. Wassermann doubtful positive. 

15, 1912. Wassermann negative. 

— , 1909. Primary lesion. Treated ten months with mercury. 

29. 1911. Wassermann positive. No symptoms at present. 
2, 1912. Wassermann negative. 

Had two doses of 606 in the interval. 
Primary lesion six months ago ; 606 four months ago. 
June 21, 1910. No symptoms at present. Wassermann negative. 
Primary lesion six years ago. 

Dec. 7, 1910. Orchitis, dactylitis. Wassermann positive. 
Dec. 8. 0.9 gm. 606 intramuscularly. 

Dec. 18. Wassermann positive. 

Mar. 2, 1911. Wassermann positive. 



Oct. 
Nov. 
Dec. 
Dec. 
Feb. 
Case 9. — Mar. 
Mar. 
Jan. 



Case 10. 
Case 11. 





Mar. 15. 




Sept. 20. 


Case 


12.— Sept— , 1910. 




July — , 1911. 




Oct. 18. 


Case 


13.— Sept. — , 1910. 




Mar. — , 1911. 




Mar. 26. 




May 27. 




June 28. 


Case 


14. — Denies syphilis. 




Oct. 16, 1911. 



REPORT OF WASSERMANN REACTIONS 249 

Wassermann positive. 

Wassermann doubtful positive. 

Primary. Treated with mercury for seven months. 

606. 

Wassermann negative. 

Primary lesion. 

Mixed treatment. 

606 subcutaneously. 

606 intravenously. 

Wassermann negative. 
Had yaws thirty-five years ago. 

Wassermann positive. Palpable tumor of liver. 
Diagnosis : Gumma of liver. 

0.5 gm. 606 intravenously, followed by mixed treat- 
ment. 
Jan. 23, 1912. Tumor not felt. General condition greatly improved. 
Wassermann positive. 

Four of the above cases, on whom no test was done before injection, 
gave a negative reaction after injection. Four, on whom the reaction 
was positive before injection, gave a negative reaction after an interval 
of three and one-half to nine months. Six cases gave a positive or 
doubtful positive reaction after an interval of seventeen days to nine 
months. 

It is conceded by most observers that in working with a hemolytic 
system it is advisable to use known amounts of both amboceptor and 
cells. Wassermann 's original method for the diagnosis of syphilis 
makes use of 1 c.c. of a 5 per cent suspension of sheep corpuscles with 
just twice the amount of amboceptor necessary to hemolyze these 
cells. Since the discovery of the existence of an anti-sheep ambo- 
ceptor in some human sera it has been a question whether this ad- 
ditional amount of amboceptor might not be sufficient to produce 
hemolysis in conjunction with a small residue of complement not 
fixed in the first stage of the reaction. If this should occur, negative 
results would thus be obtained in syphilitic cases. 

The recognition of this possibility has given rise to several modifi- 
cations of the Wassermann reaction. The best known of these is 
probably that of Noguchi. He claimed 1 that: " Wassermann 's origi- 
nal method is subject to an error arising from the presence in human 
serum of a varying amount of natural amboceptor capable of being 
reactivated by guinea-pig's complement." He found experimentally 

Noguchi. Jour. Exp. Med., 1909, xi, 392. 



250 ST. LUKE'S HOSPITAL REPORTS 

that four units of anti-sheep amboceptor prevent entirely the detec- 
tion of one unit of syphilitic antibody. The modification of the Was- 
sermann technique devised by him has, among other advantages, that 
of avoiding this danger by the use of a hemolytic system consisting 
of human blood cells and the serum of a rabbit immunized against 
them. 

Several other methods of obviating this source of error have been 
suggested which still make use of sheep corpuscles as in the original 
Wassermann method. That of Bauer 2 , in which each serum is tested 
for anti-sheep amboceptor and artificial immune serum added only to 
those which show an insufficient amount of natural anti-sheep ambo- 
ceptor to give complete hemolysis with the amounts of sheep cells 
and complement used in the Wassermann reaction, will of course be 
efficient in those cases in which the human serum contains just enough 
amboceptor to give complete hemolysis. As, however, some sera con- 
tain many times this amount of natural amboceptor, with these the 
source of error still remains. 

Jacobaeus 3 proposed absorbing the sheep amboceptor from human 
serum by incubating the serum, after the addition of sheep cells, at 
37° for one-half hour; then centrifuging off the cells and proceeding 
with the Wassermann reaction according to the regular technique. 
In a series of 257 cases he obtained about 10 per cent more positives 
by this method than without absorption. He claims that complemen- 
toid is also removed by this method, thus giving it the advantage of a 
modification introduced by Wechselmann, 4 in which complementoid 
is removed by digesting the inactivated human serum with barium 
sulphate. Bauer 5 had previously tried the same procedure which 
Jacobaeus employed, but discarded it on account of its making the 
serum anti-hemolytic. He claimed that this property was much in- 
creased by the addition of liver extract, thus causing negative sera 
to give positive reactions. 

S. Mintz 8 , using this method in a series of 38 cases, obtained 30 
positive reactions against 25 without absorption. The sera which 
reacted positively were all syphilitic. 

This method of amboceptor absorption has been tried by the author 

2 Bauer. Sem. meo\, 1908, xxviii, 429. 

'Jacobaeus. Ztschr. f. Immunitatsforsch., Orig., 1911, viii, 615. 

4 Wechselmann. Ztschr. f. Immunitatsforsch., Orig., 1909, iii, 525. 

'Bauer. Berlin klin. Woch., 1908, xiv, 834. 

6 S. Mintz. Ztschr. f. Immunitatsforsch., Orig., 1911, ix, 29. 



REPORT OF WASSERMANN REACTIONS 251 

on 305 sera, regardless of the amount of natural anti-sheep ambo- 
ceptor present. The result of the Wassermann reaction on each of 
these sera has been compared with the result of the reaction on the 
same serum with the natural anti-sheep amboceptor present. 

Only 53 of the 305 sera contained one or more units of natural anti- 
sheep amboceptor in 0.2 c.c, i.e., sufficient to hemolyze completely 1 
c.c. of a 5 per cent suspension of sheep corpuscles in the presence of 
one unit of complement. In 70 sera there was no trace of anti-sheep 
amboceptor in 0.2 c.c. In the remaining 182, anti-sheep amboceptor 
was present, but in a quantity not sufficient to produce complete 
hemolysis. 

The technique employed to remove the anti-sheep amboceptor from 
the human serum was as follows: To 0.5 c.c. of the patient's serum, 
after inactivation, was added 2 c.c. of 0.85 per cent salt solution and 
0.1 c.c. of sheep cells. After shaking, the mixture was incubated at 
37° for 20 minutes. The cells were then centrifuged off and the 
supernatant fluid used in the Wassermann reaction, 0.5 c.c. of the 
diluted serum being used in the tube with antigen and 1 c.c. in the 
control tube without antigen, the amount of antigen, complement, etc., 
being correspondingly reduced to one-half the usual quantity. The 
remainder of the fluid was used to test the completeness of the ambo- 
ceptor absorption. In about one-quarter of the cases a sufficient 
amount of the patient's serum was used to test for remaining sheep 
amboceptor in a full c.c. 

In all but three of the 305 sera, removal of the sheep amboceptor 
was complete. 0.2 c.c. of each of these showed a faint trace of hemoly- 
tic power for sheep cells still present. One additional serum showed 
very slight hemolytic power remaining in a full c.c, but none was 
demonstrated in 0.2 c.c. 

So far as the removal of anti-sheep amboceptor from human serum 
is concerned, we may conclude that the method is practically always 
efficient. The objection to the method is that inhibitory bodies are 
in some way produced by this process ("Sachs-Friedberger phenom- 
enon") which considerably slow hemolysis, there sometimes being a 
trace of inhibition at the end of an hour in the control tubes and in 
negative sera. The difference in reaction between positive and nega- 
tive sera is, however, clear-cut, the inhibitory action not being suffi- 
ciently marked to render the method impracticable as a means of 
avoiding any error which may be due to the presence of natural anti- 
sheep amboceptor. 



252 ST. LUKE'S HOSPITAL REPORTS 

Rossi 7 claims that incubation at 0° for 20 minutes is as efficient in 
absorbing the amboceptor as incubation at 37°, while by this method 
the inhibitory phenomenon does not appear. His method is to add 
0.5 c.c. of sheep red blood corpuscles to 1.5 c.c. of the patient's serum, 
both having been previously cooled to 0°. The mixture is kept at 
this temperature for 20 to 30 minutes, then rapidly centrifuged, and 
the serum drawn off with a pipette. In a series of 60 syphilitic cases 
he obtained 50 positives by the Wassermann reaction and 56 positives 
after absorption. 

This method of absorption, as well as that at 37°, was tried on 
195 of the above 305 sera. In a portion of these the Rossi technique 
was followed in detail. With the remainder, the technique was the 
same, except that serum and cells were mixed in the proportions used 
for absorption at 37°. This method was found equally efficient in 
absorbing the anti-sheep amboceptor. So far, however, as the avoid- 
ance of inhibitory action is concerned, it was unsuccessful, there 
being little if any difference in this regard between the two methods. 

The results of the Wassermann reactions on the 305 sera with 
natural anti-sheep amboceptor still present and on the same sera 
after the amboceptor has been completely removed, are shown in the 
following table. The results of the Wassermann reaction, following 
absorption at 0° did not differ in any particular from those following 
absorption at 37°. 

Doubtful Doubtful 
Wassermann reaction Positive positive negative Negative 
On sera with natural anti-sheep ambocep- 
tor present 103 16 2 184 

On sera after removal of anti-sheep ambo- 
ceptor 104 18 1 182 

As is shown by the above table, there was a difference in results 
in but three of the 305 cases. The cases in which the reaction differed 
were as follows: 

1. Diagnosis : Pyorrhea Alveolaris. No history of syphilis obtainable. 
The serum contained five units of anti-sheep amboceptor. Wassermann reac- 
tion : with anti-sheep amboceptor present, negative ; after removal of anti-sheep 
amboceptor, doubtful positive. 

2. Diagnosis : Syphilitic Laryngitis. Primary lesion fourteen years ago. 
Treatment previous to Wassermann reaction not known. The serum contained 
over three units of anti-sheep amboceptor, the exact amount not being de- 

7 Rossi. Ztschr. f. Immunitatsforsch.. Orig., 1911, x, 321. 



REPORT OF WASSERMANN REACTIONS 253 

termined. Wassermann reaction : with anti-sheep amboceptor present, doubtful 
negative; after removal of anti-sheep amboceptor, positive. 

3. Diagnosis : Tabes Dorsalis. No history of syphilis. Serum contained 
two units of anti-sheep amboceptor. Wassermann reaction : with anti-sheep 
amboceptor present, negative ; after removal of anti-sheep amboceptor, doubtful 
positive. 

It will be noted that in none of these cases was the difference in 
results a difference between a frank negative and a frank positive 
reaction. 

In reporting results of the Wassermann reaction it is unnecessary 
to give in detail the technique employed, the method being so well 
known. There are, however, certain points which it seems to us 
should be mentioned. In the reactions reported here, the guinea-pig 
serum was always titrated and care taken never to use as much as two 
units, as will frequently be done if 0.1 c.c. is used. The antigen used 
in nearly all of the 305 cases was an acetone-insoluble fraction of 
beef heart, prepared as recommended by Noguchi 8 . The quantity 
used in the reaction was 0.01 c.c. This antigen was not hemolytic or 
anti-complementary in four times this amount, and had high anti- 
genic properties. Titrated against four positive sera it gave with 
one complete inhibition in one-tenth the quantity used ; with a second, 
complete inhibition in one-thirteenth, and with the other two com- 
plete inhibition in one-twentieth the quantity used. 

As the results obtained by the amboceptor absorption methods vary 
considerably from those reported by Wechselmann and other ob- 
servers, experiments were done to test the effect of the introduction 
of artificial amboceptor on the Wassermann reaction done with the 
above antigen. 

Three sera were selected which were frankly positive with this 
antigen and Wassermann reactions done on each of these after the 
addition of five, ten, and fifteen units of artificial anti-sheep ambo- 
ceptor. Reactions were also done on the same sera without the ad- 
dition of artificial amboceptor and after the addition of five, ten, and 
fifteen units, using an amount of antigen which by titration with each 
serum contained two units of antigen for that serum. Each serum 
contained natural anti-sheep amboceptor, but in an amount less than 
one unit. This was not removed. 

Serum 1. — Contained two units of syphilitic antibody. Wassermann reac- 
tions were positive with both strong and weak antigens. With the addition of 

"Noguchi. Serum Diagnosis of Syphilis, 2d Edition. 



254 ST. LUKE'S HOSPITAL REPORTS 

five, ten and fifteen units of amboceptor, the reactions were doubtful or nega- 
tive with both antigens, but the inhibition was greater with the stronger 
antigen. 

Serum 2.— Contained eighteen units of syphilitic antibody. Wassermann 
reactions were frankly positive with the strong antigen, even with the addition 
of five, ten and fifteen units of amboceptor. With the weak antigen the serum 
gave a frankly positive reaction when artificial amboceptor was not added. 
With five units of amboceptor the reaction was doubtful ; with ten and fifteen 
units, negative. 

Serum 3. — Contained more than twenty-five units of syphilitic antibody. 
Wassermann reactions were frankly positive with both antigens, with fifteen 
units of anti-sheep amboceptor present. 

CONCLUSIONS. 

From the above cases and experiments, we conclude that it is pos- 
sible for anti-sheep amboceptor in human serum to affect the Wasser- 
mann reaction, but that when an antigen of high titer is used this 
is possible only with sera of very low antibody content and several 
units of anti-sheep amboceptor. As these two conditions, in our ex- 
perience, occur but rarely in practical work, we feel that, when a 
strong antigen is used, the importance of anti-sheep amboceptor in 
human serum as a cause of negative reactions in syphilitic cases is 
not great. As a routine procedure, the absorption of amboceptor is 
unnecessary. Its removal is advisable, however, from sera which 
give a negative or doubtful reaction, and which contain a large 
amount of anti-sheep amboceptor. This is easily accomplished by 
digestion with sheep cells. It is immaterial whether this is done at 
0°, 37°, or room temperature. 



COMPLEMENT IN HUMAN SERUM.* 
C. H. Bailey, M.D. 

C. C. Bass 1 , in "A New Conception of Immunity," draws inter- 
esting conclusions from several statements, the experimental proof 
of which, unfortunately, he does not give. The broad application 
made of the principles stated, and the fact that, as stated, they are 
contrary to generally accepted ideas, encouraged the following brief 
experiments. 

The statements referred to are as follows: 

"Human complement capable of acting with human amboceptor to 
produce lysis ... is destroyed by any temperature above normal 
body temperature. ... A temperature of 40° C. (104° F.) 
destroys complement in human serum in from fifteen to thirty min- 
utes and prevents lysis regardless of the amount of amboceptor em- 
ployed. ' ' 

"Freshly drawn human blood contains little or no complement 
capable of acting with human amboceptors. . . . No human spe- 
cific complement develops at ordinary fever heat, 38° to 40° C. (101° to 
104° F.), such as obtains locally and often generally in most in- 
flammations. ' ' 

"In the event that human complement has developed in a blood 
... it again disappears in from thirty to seventy-two hours. ..." 

EXPERIMENTS. 

Experiment 1. — Five human serums, all of which had been on the clot for 
over seventy-two hours, were withdrawn, and tested for complement, before 
and after heating at 40.5° C. for thirty minutes. 

To tubes, each of which contained 0.25 c.c. of a 2 per cent suspension of 
washed calf-cells and 0.25 c.c. (two units) of a 1-600 dilution of inactivated 
serum of a rabbit immunized to calf -cells, was added the human serum in the 
following amounts : 0.8, 0.4, 0.2, 0.05 and c.c. A similar series was set up for 

♦Reprinted from the Journal of the American Medical Assn., 1911, lvii, 
Dec. 23. 

^ass, O. C. : Jour. A. M. A., Nov. 4, 1911, p. 1534. 

255 



256 ST. LUKE'S HOSPITAL REPORTS 

each patient, with like amounts of serum, heated for thirty minutes at 
40.5° C. 

Patients A and B gave no hemolysis with either heated or unheated serum. 
Patient C gave complete hemolysis with 0.4 c.c. of serum, both heated and 
unheated. Patient D gave slight hemolysis with 0.8 c.c. of serum, heated and 
unheated. Patient E gave complete hemolysis with 0.8 c.c. of serum, and almost 
complete with 0.4 c.c, heated and unheated. 

This experiment shows that complement may still be present in 
serums over seventy-two hours old, capable of completing a lytic sys- 
tem, and that such complement is not destroyed by thirty minutes' 
heating at 40.5° C. It would be remarkable if human complement 
capable of acting with a calf -immune system were not destroyed by 
thirty minutes' heating at 40° C, while "human complement capable 
of acting with human amboceptor to produce lysis" were thus de- 
stroyed. As, however, the article in question specifies the latter, the 
following experiment was performed to determine this point, as well 
as the truth of the statement that "freshly drawn human blood con- 
tains little or no complement capable of acting with human ambo- 
ceptors. ' ' 

Experiment 2. — A normal individual was bled directly into an equal amount 
of citrate solution in a water bath at 41° C. The cells were immediately cen- 
trifuged off, and varying amounts of the supernatant fluid added to a 5 per 
cent suspension of sheep cells, previously sensitized with human serum con- 
taining natural sheep amboceptor, and set up in the bath at 41° C. Incubation 
was at 41° to 43° C, for thirty minutes. 

The remainder of the supernatant fluid was retained in the bath at 41° to 
43° C, for thirty minutes, and then added to sensitized cells. 

To tubes, each of which contained 0.25 c.c. of a 5 per cent suspension of 
washed sheep-cells and 0.125 c.c. (=2 units) of human serum containing anti- 
sheep amboceptor, inactivated one-half hour at 56° C, was added the citrated 
plasma, prepared as above described, in the amounts given in Table I. 

TABLE I. COMPLEMENT CONTENT OF PLASMA OF NOEMAL INDIVIDUAL. 



-Result- 



With plasma heated 

With fresh plasma 30 min. at 41° C. 

Citrated plasma Hemolysis Hemolysis 

0.6 Complete Complete 

0.3 Complete Complete 

0.15 Almost complete Almost complete 

0.075 Partial Partial 

0.0375 Slight Slight 

.0 None None 



COMPLEMENT IN HUMAN SERUM 257 

Experiment 3. — Two patients, one with a temperature of 104° F., the other 
104.5° F., were bled directly into equal amounts of citrate solution, in a water 
bath, at a temperature of 42° C. The cells were at once centrifuged off, and 
the plasma, thus diluted, added to sheep cells sensitized with human serum, 
as in Experiment 2, already in the bath at 42° C. Incubation was at 42° C, 
for thirty minutes. 

TABLE II. — COMPLEMENT CONTENT OF PLASMA OF FEBEXLE PATIENT. 



Fresh citrated , Result * 

plasma from Patient A Patient B 

febrile patients Hemolysis Hemolysis 

0.6 Complete Complete 

0.3 Complete Complete 

0.15 Complete Almost complete 

0.075 Partial Partial 

0.0375 Slight Slight 

.0 None None 

From the above experiments the following conclusions seem jus- 
tified : 

1. Human complement capable of acting with human amboceptor 
to produce hemolysis is not destroyed by a temperature of 41° C. for 
thirty minutes. 

2. Freshly drawn human blood contains a considerable amount of 
complement capable of acting with human hemolytic amboceptor, and 
such* complement is not destroyed by heating at 41° C. for thirty 
minutes. 

3. The blood of a patient with a temperature of 40° C. contains 
complement capable of acting with human hemolytic amboceptor. 

4. Complement does not necessarily disappear from human serums 
in seventy-two hours after withdrawal from the body. 



EFFECTS ON TITRATIONS OF INEQUALITY OF SENSITI- 
ZATION OF CORPUSCLES.* 

C. H. Bailey, M. D. 

It is well known that corpuscles will absorb many times the amount 
of specific amboceptor necessary to produce hemolysis, and that such 
absorption takes place with considerable rapidity. We believe, how- 
ever, that the importance of these facts in quantitative serum work, 
as titrations for lytic or complementary power, has not yet been 
recognized. The author has frequently noted that duplicate titrations 
of the same serum gave results that differed beyond reasonable limits 
of experimental error, and that the reading obtained from a serum 
titration could be influenced considerably by slight variations in the 
method of activating the corpuscles. These results appear to be due 
to the fact that when corpuscles are added to an amboceptor dilution 
they are not at once evenly distributed through the fluid, and thus, 
owing to the rapidity with which amboceptor is absorbed, an oppor- 
tunity is afforded for certain corpuscles to take up more of the ambo- 
ceptor than others, and unequal sensitization results. If this be the 
case, it will be seen that slight variations in the method of activating 
the corpuscles will produce variations in the distribution of ambo- 
ceptor and consequently in the hemolysis obtained. 

The following complement titrations illustrate the difference in 
results which are produced by different methods of activating the 
corpuscles : 

Experiment I. — The tubes contained a 1-10 dilution of guinea-pig serum, 
in the amounts shown below, with sufficient salt solution to make the final total 
in each tube 1.25 c.c. 

A. To each tube was added 0.25 c.c. of a 1-2000 dilution of amboceptor 
(= 1 unit) and 0.25 c.c. of a 5 per cent suspension of sheep corpuscles, sep- 
arately. 

B. Into 4 c.c. of a 1-2000 dilution of amboceptor were dropped, rapidly, but 
one drop at a time, 4 c.c. of a 5 per cent suspension of sheep corpuscles, the 

♦Reprinted from the Journal of Experimental Medicine, May, 1912, xv. 

258 



SENSITIZATION OF CORPUSCLES 259 

receptacle being shaken in the meantime. Of this mixture, 0.5 c.c. was added 
to each tube. 

C. Like B, except that the process was reversed, the amboceptor being 
added to the corpuscles ; 0.5 c.c. was added to each tube. 

D. Into 4 c.c. of the 5 per cent suspension of corpuscles was quickly poured 
4 c.c. of the amboceptor dilution, and the mixture immediately shaken ; 0.5 c.c. 
was added to each tuba 

The results, after incubation for one hour at 37°, were as follows : 

Guinea-pig serum, 

1-10 dilution... .375.3 .25 .225.2 .175.15 .125.1 .075.05 .025 

A C C C C C AC AC AC P P YS YS 

B VS VS VS VS VS VS VS VS VS VS VS VS 

C C C C C C C C AC AC P VS VS 

D C C C C C C C C ACP VSVS 

Note. — In this and the following experiments C = complete hemolysis, 
AC = almost complete hemolysis, P = partial hemolysis, S = slight hemolysis, 
VS = very slight hemolysis, and = no hemolysis. 

It is to be noted that although the amounts of amboceptor, com- 
plement, and cells, and the dilutions, are the same in corresponding 
tubes of the different series, the results differ considerably. B and C 
are methods of activation which would hardly be used in practical 
work. They serve, however, to illustrate the extreme variation in 
results which may be obtained. It is evident in B that practically 
the entire amount of amboceptor was taken up by the first few 
corpuscles added, consequently they were the only ones to hemolyze ; 
and there is little difference in the amount of hemolysis resulting 
between the highest and lowest tubes. C, on the other hand, as might 
be expected, approaches closely to an even sensitization. A and D are 
methods which are often used in complement titration, as for the 
Wassermann reaction, A probably more commonly than D. When 
a cell suspension is added to small tubes containing amboceptor, as 
was done in A, it may be noted that frequently a few cells will be 
distributed through the liquid, the greater bulk, however, remaining 
on the surface, along the side of the tube, or sinking to the bottom, 
thus affording an opportunity for a few cells to absorb more than 
their share of the amboceptor, the amount depending, of course, on the 
interval elapsing between the introduction of the cells and the shaking 
of the tube. 

It is evident that to cause this inequality, the absorption of ambo- 
ceptor by corpuscles must be very rapid. The following experiment 
was done to obtain some idea of the amount of amboceptor absorbed 
by corpuscles in a given time : 



260 ST. LUKE'S HOSPITAL REPORTS 

Experiment II. — Amboceptor absorption in A, with a 5 per cent suspension 
of sheep corpuscles, and corresponding immune rabbit serum ; in B, with a 
2 per cent suspension of sheep corpuscles and corresponding immune rabbit 
serum. The amboceptor was so diluted as to contain 1, 2 and 5 units of 
amboceptor for equal quantities of the 5 per cent and 2 per cent suspension 
of cells. 

a. To 4 c.c. of diluted amboceptor, in a centrifuge tube, was added 4 c.c. 
of corpuscle suspension, and the mixture immediately centrifuged, at a speed 
of about 2,000 revolutions. 

b. Like a, except centrifuged after an interval of 2 minutes. 

c. Like a, except centrifuged after an interval of 5 minutes. 

From each was taken 0.5, 1, 1.5 and 2 c.c. of the diluted amboceptor, 0.5 
being approximately equivalent to 0.25 of the original amboceptor dilution, and 
to each of these amounts was added 0.2 c.c. of a 1-10 dilution of guinea-pig 
serum (= 1 unit by previous titration) and 0.25 c.c. of corpuscle suspension, 
each tube being immediately shaken after the addition of the corpuscles. For 
the control tubes the amboceptor was diluted with equal parts of salt solution. 
After incubation at 37° for one hour the results were as follows : 

Amboceptor 0.5 1 1.5 2 

A. Five per cent suspension of sheep corpuscle 

1 unit of amboceptor 

Control C 

a 

b 

c 

2 units of amboceptor 

a VS 

b 

c 

5 units of amboceptor 

a C 

b P 

c S 

B. Two per cent suspension of sheep corpuscle 

1 unit of amboceptor 

Control C 

a 

b 

c 

2 units of amboceptor 

a P 

b 

c 

5 units of amboceptor 

a C 

b C 

c P 



c 


c 


c 








VS 




















p 


p 


AC 


VS 


p 


AC 


VS 


VS 


s 


c 


c 


c 


c 


c 


c 


p 


AC 


AC 


c 


c 


c 


s 


p 


AC 








VS 











c 


c 


c 


p 


AC 


AC 


VS 


s 


P 


c 


c 


C 


c 


c 


c 


c 


c 


c 



SENSITIZATION OF CORPUSCLES 261 

It appears from the above experiment that a 5 per cent suspension 
of corpuscles almost completely absorbed one unit of amboceptor in 
the brief time necessary to centrifuge off the cells. About three- 
quarters of the 2 units of amboceptor appear to have been absorbed 
in the same length of time, while of the 5 unit amboceptor 1 unit at 
least remained. Absorption by the 2 per cent suspension was ap- 
parently not so rapid. About three-quarters of the 1 unit and about 
one-half of the 2 unit amboceptor were absorbed in the time taken 
to centrifuge, while of the 5 units at least 1 unit remained even after 
absorption for 2 minutes plus the time taken to centrifuge. 

Definite conclusions, however, cannot be drawn from such an 
experiment as to the exact amount of amboceptor absorbed or the 
relative speed of absorption by the 5 per cent and 2 per cent suspen- 
sion of corpuscles, as it is not known to what extent the failure of 
hemolysis may be due to inhibitory bodies produced by the addition 
of corpuscles for the purpose of amboceptor absorption ("Sachs- 
Friedberger phenomenon"). Such inhibitory bodies probably do not 
greatly influence the results obtained in this experiment, but if pres- 
ent it is natural to suppose that they are in larger amount after 
absorption with a 5 per cent suspension of corpuscles than after 
absorption with a 2 per cent suspension of corpuscles. 

Though the cells were centrifuged from the fluid as quickly as 
possible, an interval of between 1 and 2 minutes probably elapsed 
before their complete removal. The following experiment was done 
to show that an appreciable amount of amboceptor is absorbed in a 
considerably shorter time than this. 

Experiment III. — A 1-10 dilution of guinea-pig serum was used in the 
amounts given below, with sufficient salt solution in each tube to make the 
final total 1.25 c.c. A 5 per cent and a 2 per cent suspension of sheep corpus- 
cles, and a 5 per cent and a 2 per cent suspension of calf corpuscles were used 
with one unit of the respective amboceptor ; 0.5 c.c. of the corpuscle suspension, 
activated as follows, was added in series : 

A. 3 c.c. of the corpuscle suspension was poured into 3 c.c. of amboceptor 
dilution, and quickly shaken. 

B. 0.5 c.c. of the corpuscle suspension was poured into 3 c.c. of ambo- 
ceptor dilution, shaken, and, 15 seconds later, 2.5 c.c. of the corpuscle suspen- 
sion added. 

C. Like B, except with 50 seconds interval. 

D. Like B, except with 1 minute interval. 

E. Like B, except with 2 minutes interval. 

After incubation at 37° for one hour the results were as follows : 



262 ST. LUKE'S HOSPITAL REPORTS 

Guinea-pig serum diluted 1-10 5 .4 .3 .25 .2 .125.062.031.015 

5% suspension of sheep corpuscles 

A C C C C C C AC S VS 

B C C C C AC AC P S 

C C C C AC AC P S VS 

D AC AC AC P P P S VS 

2% suspension of sheep corpuscles 

A C C C C C AC VS 

B CCCCCPVSO 

C C C C C AC P VS 

D .' C C AC AC P S VS 

E AC P P S S VS VS 

5% suspension of calf corpuscles 

A C C C C C C AC VS 

B C C C C C AC P VS 

C C C AC AC AC AC P VS 

D C C AC AC AC P VS VS 

E AC AC P P S S VS VS 

2% suspension of calf corpuscles 

A C C C C AC P VS VS 

B C C C C AC P VS 

C C C C AC P VS VS 

D C C AC P VS VS VS 

E AC AC AC P VS VS VS 

It will be seen by the foregoing experiment that a considerable 
effect is produced on the degree of hemolysis obtained by a contact of 
even 15 seconds of a portion of the corpuscles with the amboceptor 
before the introduction of the remainder. The effect is somewhat less 
marked with the 2 per cent than with the 5 per cent suspension. This, 
we believe, is what takes place in greater or less degree in any serum 
titration when an even distribution of the corpuscles throughout 
the amboceptor dilution is not at once obtained. It is probably im- 
possible to obtain an absolutely even sensitization. The nearest ap- 
proach to this is produced by quickly pouring the diluted immune 
serum into an equal volume of the corpuscle suspension, which is 
shaken during and for a short period after the mixing (Exp. I, D). 
If the corpuscles are poured slowly into the amboceptor or intro- 
duced in separate lots, as with a 5 or 10 c.c. pipette, unequal sensitiza- 
tion will result. This is illustrated in an extreme degree by the 
method of sensitization used in Exp. I, B, that of dropping the cells 
into the amboceptor. It is to be noted that the reading is not only 
higher with an even sensitization, but is also sharper; that is, the 



SENSITIZATION OF CORPUSCLES 263 

change from complete hemolysis to entire lack of hemolysis, instead 
of being gradual, is quite sudden (Exp. I, A and D). 

The importance in practical work of obtaining as uniform a dis- 
tribution of amboceptor as possible is obvious, as well as the necessity 
in any comparative titration of using suspensions of activated cells 
in the various titrations which are exactly alike as to the distribution 
of amboceptor. The importance of complement titration for the 
Wassermann or other complement absorption tests is rightly empha- 
sized. If, however, the same method of sensitization is not used in 
this titration as is used in the final stage of the Wassermann reaction, 
the titration is of little value as an index of the activity of the serum. 
It is a common practice to introduce amboceptor and corpuscles sep- 
arately in a complement titration (Exp. I, A), while corpuscles 
previously sensitized in bulk are used in the Wassermann reaction. 
By the latter method it is much easier to approximate an even sen- 
sitization (Exp. I, D). Thus the reading obtained in a complement 
titration in which amboceptor and corpuscles are added separately 
would lead one to use an excess of complement in performing the 
reaction. 

In an amboceptor titration, the immune rabbit serum and cor- 
puscles are usually introduced separately — to employ separate lots 
of corpuscles previously activated with each dilution would be an 
exceedingly tedious task — yet if one accepts the highest dilution with 
which complete hemolysis is obtained as the titer of the serum, and 
with this dilution titrates the same complement as was used in the 
amboceptor titration, hemolysis will be obtained, provided more evenly 
sensitized corpuscles are here used, with considerably less complement 
than was used in the amboceptor titration. This may be illustrated 
by reference to Experiment III. It is stated in this experiment that 
one unit of amboceptor was used. Both the anti-sheep and the anti- 
calf amboceptor were titrated before this experiment, using 0.25 c.c. 
of the same dilution of guinea-pig serum as was used in the experi- 
ment. The anti-sheep serum was found to give complete hemolysis of 
the 5 per cent corpuscles in a dilution of 1 to 800, incomplete in 1 
to 1,000 ; the anti-calf gave complete hemolysis of the 5 per cent cor- 
puscles in a dilution of 1 to 400, incomplete in 1 to 600. In the ex- 
periment, however, in which they were used in dilutions of 1 to 800 
and 1 to 400, respectively, we find that they both give complete hem- 
olysis when previously sensitized corpuscles are used (Exp. Ill, A) 
with one-half the amount of complement (0.125 c.c.) with which they 



264 ST. LUKE'S HOSPITAL REPORTS 

were titrated. A retitration of the anti-sheep serum with 0.25 c.c. of 
the complement dilution, using 0.5 c.c. of corpuscle suspension previ- 
ously activated for each dilution by rapidly mixing 5 c.c. of a 5 per 
cent suspension of corpuscles with an equal amount of the proper 
amboceptor dilution, gave complete hemolysis in a dilution of 1 to 
1,200. We must conclude, then, that an amboceptor as well as a 
complement titration is influenced by the evenness of the sensitization 
of the corpuscles. 

CONCLUSIONS. 

The absorption of amboceptor by corpuscles is rapid, a consider- 
able amount being absorbed in as short a period as 15 seconds. In the 
sensitization of corpuscles, the amount of amboceptor absorbed by 
the different corpuscles is not uniform, the inequality depending on 
the time taken in obtaining an even distribution of the corpuscles 
through the diluted immune serum. Amboceptor absorption is ap- 
parently influenced by the concentration of the corpuscles, being more 
rapid with a 5 per cent than with a 2 per cent suspension, and thus 
the stronger concentration is more susceptible to inequality of sen- 
sitization from variations in the method of activation. 

In experimental work it is of importance to obtain as equal a 
sensitization as possible. It is essential that in comparative titrations 
the same method of activation be employed in the several titrations, 
and where possible, it is advisable that all the cells to be used be 
sensitized together in bulk. 

The results obtained in titrating hemolytic sera and complement 
depend to a considerable extent on the evenness of sensitization of the 
corpuscles. 



THE DETERMINATION OF COPPER— A MODIFICATION OF 
THE IODIDE METHOD.* 

E. C. Kendall, Ph.D. 

For the determination of copper the most important methods are 
the electrolytic, the iodide, and the cyanide. As the determination by 
means of the electrolytic method requires a considerable amount of 
time and apparatus, the only methods for the rapid estimation of 
copper are the iodide and the cyanide. 

Upon an examination of the two volumetric methods mentioned it 
is apparent that in respect to the amount of time and attention re- 
quired for a determination the cyanide has a great advantage over 
the iodide method. However, in respect to the accuracy of the results 
obtained the iodide method is conceded to be by far the more accurate 
of the two. As every consideration would be in favor of the iodide 
method if it could be modified in such a way as to make it as rapid 
and easy of manipulation as the cyanide method, an attempt was made 
to make such a modification. 

In the determination of copper by the iodide method the copper 
may be originally present as copper, copper oxide, or sulfide. The 
first step is to obtain the copper in solution. Practically the only way 
to do this is to dissolve it in nitric acid. The solution of the copper 
with nitric acid produces nitrous acid in the solution, and it is the 
removal of this which causes the delay in the estimation of the copper. 
As the method is described in the literature, the nitrous acid is de- 
stroyed with bromine, the excess of bromine being removed by boiling ; 
or the nitrous acid is removed by evaporating to dryness. 

The modification of the iodide method as described in this paper 
consists in the destruction of the nitrous acid without boiling. This 
is accomplished by the addition of a small amount of sodium hypo- 
chlorite. The addition of sodium hypochlorite to a nitric acid solution 
produces hypochlorous acid. The interaction of hypochlorous acid 

♦From the Journal of the American Chemical Society, vol. xxxiii, No. 12, 
December, 1911. 

265 



266 ST. LUKE'S HOSPITAL REPORTS 

and nitrous acid results in the oxidation of the nitrous acid and the 
formation of hydrochloric acid, and the reaction between hypochlorous 
and hydrochloric acid results in the destruction of the hypochlorous 
acid and the formation of free chlorine and water. As the solution 
of sodium hypochlorite contains small amounts of chlorides, hydro- 
chloric acid will always be present when the solution is acidified, thus 
insuring the destruction of the hypochlorous acid and the formation 
of free chlorine. We thus see that the effect of adding sodium hypo- 
chlorite to the solution is the complete destruction of the nitrous acid 
and the formation of free chlorine. 

To remove the free chlorine in solution some compound must be 
added which will take up the chlorine, but will not affect subsequent 
operations. Such a compound is found in phenol. Under the condi- 
tions of the determination, phenol will add chlorine directly to the 
benzene ring, but is not affected by iodine or any of the other com- 
pounds in the solution. Chlorophenol not being ionized removes all 
traces of free chlorine. 

This modification of the method greatly reduces the time and at- 
tention required for a determination, and, in addition, the copper 
solution is prepared in such a way that iodine can be liberated by 
copper alone. 

In the determination, the copper, copper oxide, or sulfide is dis- 
solved in nitric acid. After the addition of the sodium hypochlorite 
and phenol, which requires but a moment, the solution is made slightly 
alkaline with sodium hydroxide, and is then made acid with acetic acid, 
when the solution is ready for titration. Potassium iodide and starch 
are added, and the titration is made to the disappearance of the starch 
iodide color. There is never any fear of the blue color "flashing 
back," and the solutions will remain colorless indefinitely after the 
titration. As the ionization constant for acetic acid is too low to 
allow nitrates to liberate iodine, the amount of nitric acid in solution 
is immaterial. Even 20 c.c. of concentrated nitric acid will not affect 
the titration. However, too great an acidity is to be avoided, as 
nitrophenol will be formed. The presence of nitrophenol prevents 
the determination of copper, but there is no danger of its formation 
even in the presence of a large amount of acid if the solution is neu- 
tralized soon after the addition of the phenol. If a large amount of 
nitric acid is used to dissolve the copper, it should therefore be partly 
neutralized before addition of the phenol. 

As chlorine easily oxidizes phenol to compounds which prevent the 



THE DETERMINATION OF COPPER 267 

determination of copper, it is essential that all of the phenol be added 
quickly to the solution. Under these conditions the chlorine adds 
directly to the benzene ring, but if the phenol is added drop by drop 
the chlorine will oxidize it, producing colored compounds in solution. 

In order to add the phenol quickly enough to the solution it may be 
poured in from a beaker, or, a more convenient way, from a pipette 
from which the tip has been removed so that the delivery is from an 
opening which is of the same bore as the rest of the tube. By forcing 
the phenol out of such a pipette with the breath, the entire volume is 
added very quickly and at the same time the phenol is well mixed with 
the contents of the flask. 

After addition of the phenol the chlorine gas which is in the flask 
above the liquid is removed by blowing it out with the breath, and 
the sides of the flask are washed with a jet of water from a wash 
bottle. There should be no odor of chlorine just before the solution, 
is made alkaline. 

It should be remembered that the end point of the titration is not 
pure white. Cuprous iodide has a cream color, and when a large 
amount of copper is present the cuprous iodide gives a decided tint 
to the solution. When the end point is nearly reached a drop of the 
thiosulfate is allowed to fall into the center of the flask. If a change 
of color occurs the solution is given a slight rotary motion and after 
the solution is again quiet another drop of the thiosulfate is added. 
This "spot test" is easily recognized and gives a very accurate end 
point. 

The speed of reaction of the copper with potassium iodide varies 
with the volume. In a small volume the action is rapid and all of the 
iodine is liberated at once, but in a large volume an appreciable time 
may be required for all of the copper to react. This is especially 
noticeable when a small amount of copper is present. A high con- 
centration of potassium iodide greatly assists the liberation of the 
iodine. Accurate results cannot be obtained unless at least 3 grams 
of potassium iodide are added, irrespective of the amount of copper 
present, up to 500 mg. of copper. 

The solutions required are: 1 

A. The Sodium Hypochlorite solution is made by boiling together 
a mixture of 112 grams of calcium hypochlorite and 100 grams of 
anhydrous sodium carbonate in 1,200 c.c. of water. After the calcium 

'The weights given here are for calcium hypochlorite having 35 per cent or 
more available chlorine. 



268 ST. LUKE'S HOSPITAL REPORTS 

is precipitated as carbonate, the solution is filtered and its strength 
found as follows : 5 c.c. of the hypochlorite solution are added to 100 
c.c. of water containing 5 c.c. of 30 per cent potassium iodide solution, 
and a few c.c. of dilute hydrochloric acid are added. The liberated 
iodine is titrated with 0.1 N sodium thiosulfate. The volume of the 
solution is now adjusted so that 5 c.c. of the hypochlorite solution are 
equivalent to 30 c.c. of 0.1 N sodium thiosulfate. 

B. Phenol — A 5 per cent colorless solution of phenol. 

C. Sodium Hydroxide — A 20 per cent solution. 

D. Acetic Acid, 50 per cent. 

E. Potassium Iodide — A convenient way to use this is to prepare 
a solution which contains 30 grams per 100 c.c. of solution. Then 
10 c.c. will contain 3 grams, which is the amount needed for a de- 
termination. 

F. Sodium Thiosulfate — For the accurate titration of the liberated 
iodine two solutions are used. One strong solution, 1 c.c. of which 
equals 6 mg. of copper, and a weak solution, 1 c.c. of which equals 
1 mg. of copper. The strong solution is run in until the iodine liber- 
ated by the copper gives a light straw color to the solution. Starch 
is then added and the titration is finished with the weak solution. 

As a thiosulfate solution loses strength, it should be restandardized 
from time to time. A convenient way to do this is as follows : A solu- 
tion of sodium thiosulfate, approximately 0.1 N, is made by dissolving 
24 grams of the crystallized salt per liter of water. After the solution 
has stood at least 24 hours it is standardized against copper by the 
method described below. Pure electrolytic copper which has been 
cleaned with emery paper should be used. After dissolving 150 to 
200 mg. of the copper in 6 to 8 c.c. of 50 per cent nitric acid the so- 
lution is treated as described below and the thiosulfate is then stand- 
ardized with this known weight of copper. The most convenient 
means of restandardizing the thiosulfate is to use a solution of acid 
potassium iodate. Acid potassium iodate has the formula KI0 3 .HI0 3 , 
so that a normal solution has one-twelfth the molecular weight in 
grams per liter. A 0.1 N solution is prepared by dissolving 3.249 
grams of the salt in 1 liter of water, and it is standardized against 
a known strength of thiosulfate as follows: Add 10 c.c. of the acid 
iodate solution to 150 c.c. of water containing 0.5 to 1 c.c. of hydro- 
chloric acid. Upon the addition of potassium iodide, iodine will be 
liberated according to the equation 

HIO.3 + 5HI = + 3H 2 + 61. 



THE DETERMINATION OF COPPER 209 

Starch is added and the titration is made to a colorless solution. From 
this titration the weight of copper to which 20 c.c. of this solution are 
equivalent is accurately determined. A 20 c.c. pipette is passed through 
a one-hole stopper and is allowed to remain in the acid iodate bottle. 
The end of the pipette is closed with a small rubber stopper. The ex- 
act copper equivalent of a thiosulfate solution is now easily found by 
titrating 20 c.c. of the acid iodate solution whose copper equivalent is 
known with the thiosulfate as described above. The acid iodate re- 
mains constant indefinitely. 

G. Starch for Indicator — The best preparation for this purpose is 
a 0.5 per cent solution of Kahlbaum's soluble starch. This is prepared 
as ordinary starch, but gives a perfectly clear solution which is very 
sensitive with iodine. If ordinary starch must be used it should be 
free from all cloudiness. 

DETAILED DESCRIPTION OF THE METHOD. 

If the copper to be determined is present as metallic copper, 200- 
300 mg. are placed in a 300 c.c. flask and dissolved in 5-10 c.c. of 50 
per cent nitric acid. 

If the copper is present as cuprous oxide, it is filtered on a Gooch 
crucible through asbestos. The cuprous oxide is then dissolved 
through the Gooch crucible with 10-15 c.c. of 30 per cent nitric acid 
into a 300 c.c. Erlenmeyer flask. 

If the copper is in the form of sulfide, it is filtered on a Gooch 
crucible which has a layer of asbestos one-eighth inch in thickness. 
The crucible is then placed in a small beaker of 50 c.c. capacity, and 
10 c.c. of 50 per cent nitric acid are added. The beaker is placed on 
a hot plate, and the nitric acid allowed to boil until all the black sul- 
fide has gone into solution. The crucible is then washed off, and the 
solution transferred to a 300 c.c. Erlenmeyer flask. The presence of 
the asbestos in the solution does not interfere with the titration of 
the copper. 

If the copper to be determined is already in solution as sulfate, 
chloride, or other salt, sufficient solution is taken to give 100 to 300 
mg. of copper. 

Having obtained the copper in solution, preferably in a 300 c.c. 
Erlenmeyer flask, the volume being between 50 and 60 c.c, the acidity 
is adjusted to equal 4 to 5 c.c. of concentrated nitric acid. A greater 
volume of acidity is to be avoided. The temperature should not be 
above 25°. Five c.c. of the hypochlorite solution are now added to 
the copper solution, which is well mixed with a rotary motion. As 



270 ST. LUKE'S HOSPITAL REPORTS 

soon as the color of the copper solution changes from a clear blue to 
a greenish tint, sufficient hypochlorite has been added. Another in- 
dication of a sufficient amount of hypochlorite is the liberation of 
chlorine. For weights of copper up to 200 mg., 2-3 c.c. of the hypo- 
chlorite are sufficient. For larger amounts of copper more hypo- 
chlorite may be needed, but 5 c.c. will be sufficient for any amount 
of copper which would be determined by this method. The reactions 
between the hypochlorous and nitrous acid require an appreciable time 
and the best results are obtained by allowing the solution to stand 
about 2 minutes before the addition of the phenol. This, however, 
is not essential. Ten c.c. of the phenol solution are now added as 
quickly as possible, by blowing the solution from a pipette from which 
the tip has been removed. 

The chlorine gas which remains in the flask above the liquid is re- 
moved by blowing into the flask and the sides are washed down with 
a jet of water. If the solution is allowed to stand at this point, nitro- 
phenol will slowly form. Sodium hydroxide is therefore added until 
a very slight precipitate is obtained. The solution is now made acid 
with acetic acid ; only a few drops should be required to dissolve the 
precipitate. Ten c.c. of the potassium iodide are added and the ti- 
tration made with the standardized thiosulfate. If great accuracy is 
required the titration is finished with a weak solution of thiosulfate. 

The following are some results obtained by the method described 
above. The milligrams found and the error are calculated only to a 
point which is within the degree of accuracy of the apparatus used. 



DETERMINATION OF COPPER 



Copper taken 


Copper found 


Error 


Mg. 


Mg. 


Mg. 


20.00 


20.01 


+ 0.01 


20.00 


19.99 


—0.01 


20.00 


20.00 


0.00 


30.00 


29.99 


—0.01 


30.00 


30.00 


0.00 


40.00 


39.98 


—0.02 


40.00 


39.96 


—0.04 


60.00 


60.01 


+ 0.01 


60.00 


60.01 


+ 0.01 


80.00 


80.12 


+ 0.12 


80.00 


80.03 


+ 0.03 


80.00 


79.98 


—0.02 


80.00 


79.98 


—0.02 



Error 
Per cent. 
+ 0.05 
—0.05 

0.00 
—0.03 

0.00 
—0.05 
—0.10 
+ 0.02 
+ 0.02 
+ 0.15 
+ 0.04 
—0.02 
—0.02 



THE DETERMINATION OF COPPER 



271 



Copper taken 


Coppei* found 


Error 


Error 


Mg. 


Mg. 


Mg. 


Per cent. 


100.00 


100.00 


0.00 


0.00 


100.00 


99.99 


—0.01 


—0.01 


120.00 


119.95 


—0.05 


—O.04 


140.00 


140.00 


0.00 


0.00 


160.00 


160.00 


0.00 


0.00 


160.00 


160.00 


0.00 


0.00 


180.00 


180.00 


0.00 


0.00 


180.00 


180.00 


0.00 


0.00 


200.00 


200.00 


0.00 


0.00 


200.00 


199.9 


—0.1 


—0.05 


203.2 


203.2 


0.00 


0.00 


220.2 


220.1 


-o.l 


—0.05 


240.0 


240.0 


0.00 


0.00 


240.0 


240.2 


+ 0.2 


+ 0.08 


261.6 


261.6 


0.00 


0.00 


280.0 


280.0 


0.00 


0.00 


280.0 


280.3 


+ 0.3 


+0.10 


300.0 


300.1 


+ 0.1 


+ 0.03 


320.0 


319.9 


—0.1 


—0.03 


320.0 


319.9 


—0.1 


—0.03 


340.0 


340.0 


0.00 


0.00 



Note. — The sum of the + and — errors very nearly equals zero. 



For the opportunity of carrying out this work I wish to thank Dr. 
N. B. Foster and for assistance with the analytical work Mr. A. W. 
Thomas. 



THE DETERMINATION OF IODINE IN THE PRESENCE OF 
OTHER HALOGENS AND ORGANIC MATTER. 

E. C. Kendall, Ph.D. 

During an investigation of the iodine bearing compound of the 
thyroid gland a method for the determination of small amounts of 
iodine in organic combination was worked out in this laboratory. As 
the reactions involved in this method are quantitative when larger 
amounts of iodine are present, conditions have been established which 
furnish a rapid and accurate method for the determination of iodine 
in the presence of bromides, chlorides, and organic matter. 

For the determination of iodine when present as an iodide or in 
the uncombined condition, Andrews 1 has proposed a volumetric 
method in which the iodine is oxidized to iodine chloride by means 
of iodic acid. The titration by Andrews' method is done in the 
presence of a large excess of hydrochloric acid, the end point being the 
disappearance of iodine. As the oxidation of the iodine is limited by 
the acid to the formation of I CI, one molecular weight of iodine re- 
acts with but two molecular weights of chlorine. 
El + Cl 2 = KC1 + IC1. 

If the oxidation of the iodine is carried out under conditions which 
permit the quantitative formation of iodic acid, one molecular weight 
of iodine requires six molecular weights of chlorine, as shown by the 
equation 

Kl + 3C1 2 + 3H 2 = KC1 + HI0 3 + 5HC1. 
Dupre's method for the determination of iodine is based upon this re- 
action, weak chlorine water being used for the oxidation. In a recent 
paper by Hunter 2 a method is proposed in which the iodine is oxidized 
to iodic acid with sodium hypochlorite, and after the removal of the 
excess of hypochlorite the weight of iodic acid is determined by the 
further addition of potassium iodide. Iodic acid and potassium iodide 
react as follows: 

HI0 3 + SHI = 31, + 3H 2 0. 

'Jour. Amer. Chem. Soe, 25, 756. 

s Jour. Biological Chem. (1910), vol. vii, p. 321. 

272 



THE DETERMINATION OF IODINE 273 

The liberated iodine is titrated with sodium thiosulfate, the weight 
of iodine titrated being six times the weight originally present. 

The method described in this paper is based upon the oxidation of 
the iodine to iodic acid and the subsequent determination of the 
amount of iodic acid formed. 

DETERMINATION OF IODINE WHEN PRESENT AS AN IODIDE OR FREE IODINE. 

For the determination of iodine when present as an iodide or in the 
uncombined condition, it is necessary to have a solution of the iodine 
which is free from organic matter or oxidizing agents, such as arsenic, 
antimony, copper, nitrites, and all compounds which liberate iodine 
from potassium iodide. If bromine or any compounds which inter- 
fere are present, the method is modified as described below. 

The solution containing the iodine is placed in a 500 c.c. flask, the 
total volume of the solution being between 200 and 250 c.c. The 
solution 3 should have a neutral or very slightly alkaline reaction. 
Five c.c. of phosphoric acid (85 per cent diluted with an equal volume 
of water) are added to the solution. A solution of sodium hypo- 
chlorite 4 is now added, while the solution is shaken with a rotary 
motion. If an iodide is present iodine will be liberated, but the fur- 
ther addition of hypochlorite will oxidize this to iodic acid. The 
hypochlorite should be added slowly, and care should be taken to 
avoid adding more than is necessary to give a colorless solution. The 
solution is allowed to stand 2 to 3 minutes after becoming colorless and 
then 10 c.c. of a colorless 5 per cent solution of phenol are added. 
The phenol combines with the free chlorine in solution, forming 
chlorophenol. This compound being unionized, removes all traces of 
chlorine from the sphere of reaction. When a solution of phenol is 
slowly added to a solution containing free chlorine the phenol is 
partially oxidized, producing colored compounds, but if the phenol is 

•To prevent loss of iodine at this point the solution must be cold, and when 
more than 100 mg. of iodine are present the solution in the flask should be 
covered with a few c.c. of benzol. 

*A convenient means of preparing this reagent in a proper concentration is 
to add 112 gm. of calcium hypochloride whose available chlorine is approximately 
35% to 1,200 c.c. of water. Stir the mixture, to break up any lumps, and heat 
to boiling. One hundred grams of anhydrous sodium carbonate are now 
added, and the solution boiled 10 to 12 minutes. After cooling, the precipitate 
of calcium carbonate is filtered off and the solution of sodium hypochlorite is 
kept in a black-colored bottle. 



274 ST. LUKE'S HOSPITAL REPORTS 

all added at once the chlorine adds to the benzol ring without oxida- 
tion of the phenol. For this reason the phenol is added to the flask 
as rapidly as possible. This is accomplished by forcing the phenol 
with "the breath from a 10 c.c. pipet from which the tip has been 
removed, so that the delivery is from an opening which is the same 
bore as the rest of the tube. A few drops of phenolphthalein are 
added and the solution is made slightly alkaline with 30 per cent so- 
dium hydroxide which is free from nitrites. The solution is now made 
acid with 10 c.c. of 50 per cent phosphoric acid. Upon the addition 
of potassium iodide the iodic acid in solution will liberate iodine 
which is titrated with sodium thiosulfate. The amount of potassium 
iodide added should be sufficient to leave an excess after reacting with 
the iodic acid. The weight of potassium iodide required is, roughly, 
eight times the weight of the iodine originally present. 

The effect of the presence of small amounts of oxidizing compounds 
is considerably lessened if the solution is made alkaline and is then 
acidified again. This step is necessary to secure satisfactory results. 

The most satisfactory method for standardizing the sodium thio- 
sulfate which is used to titrate the iodine liberated by the iodic 
acid is as follows : Ten grams of freshly resublimed iodine are weighed 
out in a weighing bottle. This is placed in a large Erlenmeyer flask 
containing 5 grams of sodium hydroxide dissolved in 400-500 c.c. of 
water. The cover is removed from the bottle and the iodine is dis- 
solved in the alkali. The solution is now diluted to two liters; 1 c.c. 
will contain 5 mgms. of iodine. For standardizing, the iodine solution 
is measured into a flask, the volume is made between 200-250 c.c. and 
then the acid and hypochlorite are added as described above. The 
number of c.c. of thiosulfate divided into the weight of iodine 
measured into the flasks is the standard of the sodium thiosulfate 
for the iodine originally present. 5 If more than 100 mgms. of iodine 
are present there is danger of loss of iodine by volatilization during 
the titration. A satisfactory means of preventing this is to add a 
few c.c. of benzol to the flask. This will float on the surface and 
prevent loss of iodine. Care should be taken to finish the titration 
with starch and to shake the solution vigorously when near the end 
point. 

By the method described above the following results were obtained. 

The "original iodine" equivalent of sodium thiosulfate in this titration 
is one-sixth the amount found by the titration. Hence, if N/ 10 thiosulfate is 
used, the standard will be approximately 2.115 mg. of original iodine per c.c. 



THE DETERMINATION OF IODINE 275 

The iodine was present in the form of potassium iodide, which was 
prepared by dissolving a known weight of pure iodine in potassium 
hydroxide and reducing with metallic aluminium. 



Iodine 


Iodine 


Error 


Error 


taken 


found 


Mg. 


Per cent 


5.079 


5.077 


—.002 


.04 


5.079 


5.040 


—.039 


.76 


7.618 


7.619 


.001 


.01 


7.618 


7.630 


.012 


.15 


10.158 


10.136 


—.022 


.22 


10.158 


10.150 


—.008 


.08 


12.698 


12.717 


.019 


.15 


12.698 


12.707 


.009 


.07 


15.237 


15.166 


—.071 


.46 


15.237 


15.213 


—.024 


.16 


17.776 


17.742 


—.034 


.19 


17.776 


17.756 


—.020 


.11 


20.316 


20.337 


.021 


.10 


20.316 


20.394 


.078 


.38 


22.855 


22.820 


—.035 


.15 


22.855 


22.871 


.016 


.07 


25.395 


25.434 


.039 


.15 


25.395 


25.340 


—.055 


.22 


30.06 


30.13 


.07 


.23 


30.06 


30.13 


.07 


.23 


40.08 


40.10 


.02 


.05 


40.08 


40.10 


.02 


.05 


50.10 


50.17 


.07 


.13 


50.10 


50.30 


.20 


.39 


60.12 


60.07 


—.05 


.09 


60.12 


60.26 


.14 


.23 


70.14 


70.18 


.04 


.05 


70.14 


70.27 


.14 


.20 


80.16 


80.19 


.03 


.04 


80.16 


80.11 


—.05 


.06 


90.18 


90.20 


.02 


.02 


90.18 


90.39 


.21 


.23 


100.20 


100.12 


—.08 


.08 


100.20 


99.74* 


— .46 a 


.46 


125.45 


125.65 


.20 


.16 


125.45 


125.45 


.00 


.00 


150.57 


150.62 


.05 


.03 


150.57 


150.54 


—.03 


.02 


150.57 


150.54 


—.03 


.02 


175.66 


175.80 


.14 


.08 



"Iodine was lost, as no benzol covering was used in this determination. 



276 ST. LUKE'S HOSPITAL REPORTS 



Iodine 


Iodine 


Error 


Error 


taken 


found 


Mg. 


Per cent 


200.71 


175.59 


—.07 


.04 


200.71 


200.80 


.09 


.04 


200.71 


200.76 


.05 


.02 


225.85 


225.53 


—.32 


.15 


225.85 


226.00 


.15 


.07 


250.95 


250.91 


—.04 


.02 


250.95 


250.91 


—.04 


.02 


276.04 


275.88 


—.16 


.06 


276.04 


276.12 


.08 


.03 


301.15 


301.45 


.31 


.10 


301.14 


301.05 


—.09 


.03 


326.23 


326.02 


—.21 


.07 


326.23 


326.02 


—.21 


.07 


361.33 


350.78 


—.55 


.15 



DETERMINATION OP IODINE IN THE PRESENCE OP BROMIDES AND CHLORIDES. 

When bromine or a bromide is present in a solution to which hypo- 
chlorite is added there is no oxidation of the bromine similar to the 
oxidation of iodine. Furthermore, the presence of the bromine does 
not interfere with the oxidation of the iodine. Hydrobromic acid, 
when present in large amount, will reduce iodic acid, but all hydro- 
bromic acid may be removed by the addition of sufficient sodium 
hypochlorite. 

The method for the determination of iodine in the presence of 
bromine is as follows: The iodine (in the form of iodide or uncom- 
bined) is dissolved in 200-250 c.c. of water having a neutral or slightly 
alkaline solution. Five c.c. of phosphoric acid (85 per cent diluted 
with an equal volume of water) and 10 c.c. of benzol are added. 
Sufficient sodium hypochlorite is now added to liberate all of the 
bromine and oxidize the iodine. Iodine will be liberated at first, but 
this will be further oxidized to iodic acid. It is imperative that all 
the bromine be liberated. A small amount of powdered pumice is 
added and the solution boiled. The benzol reacts with the hypo- 
bromite and hypochlorite, forming brom- and chlor-benzol. The free 
bromine boils out of solution. A precipitate of brom-benzol may form, 
but this does not affect subsequent operations. After a few minutes' 
boiling, all traces of bromine are removed. The solution is now re- 
moved from the flame and cooled. Under these conditions, it is not 
necessary to neutralize and acidify, but the potassium iodide is added 



THE DETERMINATION OF IODINE 



277 



50 






' 0.1 g. 


50 






' 0.5 g. 


50 






' 1.0 g. 


100 






' no 


100 






• 0.1 g. 


100 






' 0.5 g. 


100 






' 1.0 g. 


250 






' n Q 


250 






' 0.1 g. 


250 






' 0.5 g. 


250 






' 1.0 g. 



directly to the cold solution. A cover of benzol should be used for 
weights of iodine over 100 mg. 

The following results show that there is no appreciable interfer- 
ence of the bromine in the determination of iodine by this method : 

50 mgms. iodine and no potassium bromide required, 26.38 c.c. sod. thiosulfate 

26.38 
26.30 
26.30 
20.50 
20.48 
20.50 
20.48 
46.10 
46.00 
46.15 
45.88 

In standardizing the sodium thiosulfate to be used when bromine 
is present, more satisfactory results are obtained by establishing the 
standard with a known weight of the iodine solution as prepared 
above, under the conditions which are described for the determination, 
of iodine in the presence of bromine. 

The presence of chlorides has no effect upon the determination of 
iodine by this method and there is no need of boiling the solution. 
The following results bear on this point: 

50 mgms. iodine and no sodium chloride required, 26.50 c.c. thiosulfate 

50 ' 1.0 g. " " " 26.50 " 

50 ' 5.0 g. " " " 26.51 " 

50 " " " 10.0 g. " " " 26.50 " 

These results were obtained by the method outlined under the 
heading, Determination of Iodine When Present as Iodide or Free 
Iodine. 

When iodine is to be determined in the presence of organic matter, 
or nitrites, copper, iron, lead, mercury, and silver, it is necessary to 
remove these interfering substances and prepare the iodine as an 
iodide for the determination. 

DETERMINATION OF IODINE IN THE PRESENCE OF ORGANIC MATTER AND 
INTERFERING ELEMENTS. 



The most satisfactory means of removing the above-mentioned sub- 
stances is by a fusion which will destroy organic matter, retain the 
iodine as an iodide, and by forming insoluble compounds, remove 
interfering elements. 

Many fusion mixtures have been proposed for the destruction of 



278 ST. LUKE'S HOSPITAL REPORTS 

organic matter, but when tried did not give entirely satisfactory re- 
sults for the peculiar needs of this method. The determination of 
iodine in the presence of organic material, as worked out in this 
laboratory, is as follows: 

DETAILED DESCRIPTION OF METHOD. 

The Fusion.* — The fusion takes place in two stages: first, the oxida- 
tion of the organic matter ; second, the reduction of all oxidizing com- 
pounds. The destruction of the organic matter is accomplished by 
fusion with a mixture of sodium potassium carbonate and potassium 
chlorate. The mixture is made by grinding together and passing 
through a 20-mesh sieve: 

138 grams of potassium carbonate (anhydrous) 
106 " " sodium carbonate (anhydrous) 
100 " " potassium chlorate (anhydrous) 

One gram or less of the organic material is placed in the bottom 
of a 2%-inch nickel crucible. This is dissolved in a few c.c. of 30 
per cent sodium hydroxide. The water is evaporated by placing the 
crucible in a hot air oven at a temperature of 150-200°. Fifteen grams 
of the fusion mixture are now added, the cover is placed on the 
crucible and the crucible is heated strongly by a large Bunsen or, 
preferably, a Meker burner. The fusion begins before the crucible is 
red hot and proceeds quietly and quickly. The crucible should be sup- 
ported on a triangle and surrounded by a collar of sheet asbestos. 
The one used in this laboratory was 3 inches in diameter, 3 inches 
deep, and one-quarter inch thick. The top of the collar was notched 
by cutting away small rectangles about 1 inch long by one-half inch 
deep. "When a cover of sheet asbestos was placed over the collar these 
notches permitted the hot gases from the burner to escape after pass- 
ing around the crucible. By heating in this manner the sides as well 
as the bottom of the crucible were heated to a red heat. After three 
minutes' heating with an 8-inch Meker burner, in a collar, as above 
described, all but a trace of the chlorate is destroyed, and the melt has 
ceased to liberate bubbles of oxygen. If the carbon content of the 

♦Since sending this article for publication this method of fusion has been 
found unreliable under certain conditions. In the Journal of the American 
Chemical Society another method of fusion will be described which can be 
relied upon under all conditions. With the exception of the fusion, the 
method is not changed. 



THE DETERMINATION OF IODINE 279 

added material is low, or if insufficient heat is applied, the fusion 
may require a longer time. 

During the destruction of the organic matter, the nitrogen con- 
tained in the protein material is in part oxidized to a nitrate. The 
action of heat on the nitrate formed results in the production of ni- 
trites in the fusion mass. If the fusion mass containing nitrites 
should be dissolved in water and acidified, the nitrous acid would 
oxidize the iodide, liberating iodine, which would be carried out of 
solution by the escaping carbon dioxide. It is therefore necessary to 
destroy the nitrites and the trace of chlorate before solution of the 
fusion mass. The most satisfactory reagent for this purpose was 
found to be metallic zinc, in granular form. The zinc must be free 
from arsenic. The size of the granules is unimportant, satisfactory 
results being obtained with both zinc dust and 20-mesh granules, 
but in order to facilitate subsequent operations, 20-mesh zinc gran- 
ules were found most convenient. 

After the first heating for 3 minutes, during which time the or- 
ganic matter is destroyed and the chlorate decomposed, 2 grams of 
the zinc are added to the crucible without removing from the flame, 
the cover is replaced, and the crucible heated in the flame for an ad- 
ditional 2 minutes. The zinc reduces all traces of chlorate and ni- 
trites. The crucible is removed from the flame and the melt is al- 
lowed to cool on the sides of the crucible. When cold, the crucible 
is nearly filled with water and placed on a hot plate. After the fusion 
mass has dissolved (this requires about 10 to 15 minutes), the solution 
is transferred to a beaker, and is then filtered to remove the excess 
of zinc and zinc oxide, and any interfering element, as lead, mercury, 
silver, copper, etc. 

In order to avoid thorough washing of the filter paper, the solution 
may be placed in a 250 c.e. flask, diluted to the mark, well mixed 
and then filtered into a 200 c.c. flask, washing out the 200 c.c. flask 
with the first 15-20 c.c. of the filtrate. The most rapid filtration we 
have found is by using a fluted filter, Carl Schleicher & Schiill, No. 
597. If no interfering element is present, filtering the solution may 
be omitted, if care is taken to decant the solution from the beaker 
into the 250 c.c. flask, leaving the granules of zinc in the beaker. The 
beaker and zinc are washed repeatedly with small amounts of water. 
The presence of zinc oxide or carbonate is not objectionable. The 
solution in the 250 c.c. flask is now adjusted to the mark of gradu- 
ation and well mixed with a rotary motion. The zinc oxide settles 



280 ST. LUKE'S HOSPITAL REPORTS 

rapidly, and after a few minutes' standing, a solution comparatively 
free from the precipitate may be decanted from the flask. The 200 
c.c. flask is washed out twice with a few cubic centimeters of this 
solution and is then filled to the mark by decanting the solution from 
the 250 c.c. flask. The iodine is now present as an iodide, free from 
interfering compounds. A few drops of methyl orange are added, 
and the solution is made very slightly acid 7 with 50 per cent sul- 
furic acid. The acidity should not be less than 2-3 c.c. (or more than 
5 c.c. ) of the 50 per cent sulfuric acid. Sodium hypochlorite is added 
until the iodine is oxidized to iodic acid. Phenol is added and the 
solution made slightly alkaline to phenolphthalein. Five c.c. of 50 
per cent phosphoric acid are now added and the iodic acid is deter- 
mined by addition of potassium iodide and titration with sodium 
thiosulfate. If bromine is present the method is varied by acidifying 
with 20 c.c. of syrupy 85 per cent phosphoric acid and adding suffi- 
cient hypochlorite to liberate all the bromine and oxidize the iodine. 
Ten c.c. of benzol are added, and the solution is boiled (with powdered 
pumice) until all bromine is expelled. Under these conditions it is 
not necessary to neutralize, but the potassium iodide is added to the 
cold solution. A cover of benzol should be used for more than 100 
mg. of iodine. 

Sulfuric acid is used to acidify the solution so that the neutraliza- 
tion will not form a salt with an ion in common with the acid used 
to acidify in the final titration. The presence of sodium phosphate 
greatly reduces the acidity from the phosphoric acid, but sodium sul- 
fate has no such action. The methyl orange being destroyed by the 
hypochlorite does not interfere with subsequent operations. If the 
color from the methyl orange is destroyed upon acidification, or if 
there is any trace of iodine liberated, the fusion was not carried out 
properly. In this case, either heating to a higher temperature or for 
a longer time will be necessary to secure accurate results. 

"When the organic matter and fusion mixture are wet with water 
and evaporated to dryness before fusion, the action of water makes 
too intimate contact between the organic matter and the chlorate, and 
a violent explosion may result. By evaporating to dryness with so- 
dium hydroxide and adding the fusion mixture to this, there is no 
danger of explosion. If some particles of carbon remain unoxidized, 

7 The presence of a few c.c. of chloroform materially decreases the foaming 
from the escaping carbon dioxide. 



THE DETERMINATION OF IODINE 281 

it does not affect the result, as all the iodine will be retained as 
iodide. 

THE DETERMINATION OF SMALL QUANTITIES OF IODINE IN ORGANIC 

COMBINATION. 

In 1910, Hunter 8 published a method for the determination of small 
quantities of iodine in organic combination, which may be briefly 
stated as follows: The compound is fused with a mixture of sodium 
potassium carbonate and potassium nitrate. This fusion destroys the 
organic matter and fixes the iodine as an iodide. The fusion mass is 
dissolved in water and sodium hypochlorite is added. Upon acidifi- 
cation with phosphoric acid, the sodium hypochlorite oxidizes the 
nitrous acid formed during the fusion to nitric acid and the iodide 
is oxidized to iodic acid. The excess of free chlorine formed from 
the sodium hypochlorite is removed by boiling. After all free chlorine 
has been removed and the solution is cold, potassium iodide is added. 
The iodic acid in solution, which was obtained from the iodine orig- 
inally in organic combination, reacts with the added potassium iodide, 
each weight of iodine present as iodic acid liberating six times its 
weight of iodine. The weight of iodine finally titrated, therefore, ifl 
equivalent to six times the amount of iodine originally present. 

During the past 18 months I have had occasion to make determi- 
nations of iodine in thyroid preparations, and the method outlined 
above was used for this work. As the results obtained were not en- 
tirely satisfactory, a careful study of the chemical reactions involved 
was undertaken, with the hope of finding a reliable method for the 
determination of iodine. The one serious and unavoidable objection 
to Hunter's method is the fact that simply boiling a solution contain- 
ing a large amount of sodium hypochlorite, to which phosphoric acid 
has been added, will not always completely remove compounds which 
liberate iodine from potassium iodide. 9 

Foerster and Jorre 10 have pointed out that when a solution of 

8 Hunter : Jour. Bio. Chem., 1910, vii, 321. 

•In this connection, Hunter says : "The reagent that gives most frequent 
trouble is the hypochloric solution. It must be reasonably fresh. If this con- 
dition be fulfilled, the commercial product often gives excellent results. Some- 
times, however, it is impossible to get a commercial solution that does not 
give values too high." 

10 J. Pr. Chem., 1899 [2], 59, 53. 



282 ST. LUKE'S HOSPITAL REPORTS 

sodium hypochlorite is acidified, oxy-chlorine compounds, among 
which may be chloric acid, are produced. The amount of chloric acid 
formed appears to depend upon the rate of acidification, the tempera- 
ture, and concentration of the acid used. 

In Hunter's method it is necessary to add the phosphoric acid to 
the solution containing a comparatively large amount of sodium hypo- 
chlorite. This results in the formation of oxychlorine acids, which, for 
a series of determinations, may vary between wide limits, depending 
upon the conditions of fusion. When the solution is boiled for 15 to 20 
minutes, these acids are broken down and expelled, but rarely are they 
entirely removed from solution. As the amount of oxidizing com- 
pounds formed in the solution is uncertain, and as a variable amount 
may be removed by boiling, no constant correction can be applied to 
the results. For large amounts of iodine this correction is inappreci- 
able, but when only a few one-hundredths of a milligram are present it 
is a serious objection. The chemical properties of chloric acid are closely 
analogous to those of iodic acid, and while some compounds will reduce 
one more easily and completely than the other, no single compound 
was found which could be satisfactorily used in a quantitative method 
to destroy chloric and leave the iodic acid unchanged. Another ob- 
jection, though less serious, is the presence of a large amount of nitrate 
in the solution of the fusion mass. Nitrates in acid solution liberate 
iodine from potassium iodide. This reaction is slow in a solution 
slightly acid with phosphoric acid, but the titration of the iodic acid 
has to be made immediately after the addition of the potassium iodide 
as iodine is slowly liberated by the nitrates. Although many attempts 
were made to modify Hunter's method by removing all oxidizing 
compounds except iodic acid, no satisfactory modification was found. 

Further investigation, however, has resulted in the following method 
for the determination of iodine, which has proved reliable* in this 
laboratory. 

The method for small amounts of iodine is carried out as for larger 
amounts described above, with the following modifications: If the 
thyroid substance is in solution the equivalent of 1 gram of organic 
substance is placed in the 2%-inch nickel crucible and the water is 

♦Since sending this article for publication this method of fusion has been 
found unreliable under certain conditions. In the Journal of the American 
Chemical Society another method of fusion will be described which can be 
relied upon under all conditions. With the exception of the fusion, the method 
is not changed. 



THE DETERMINATION OF IODINE 283 

evaporated by placing the crucible in a hot-air oven at 150-200°. The 
15 grams of fusion mixture are now added and the fusion carried out 
as described. 

If the substance is in powder form, 1.2 grams are intimately mixed 
with 15 grams of the fusion mixture, and no water is added, but the 
fusion is carried out under the same conditions of heating and reduc- 
tion with 20-mesh zinc granules. The zinc granules are separated 
from the fusion mass by filtering or decanting as described above. 
To the solution of the fusion mass 20 c.c. of syrupy 85 per cent phos- 
phoric acid are added by allowing the acid to run from the pipet di- 
rectly into the flask. There should be no liberation of iodine at this 
point. A few drops of bromine are added to the flask and the so- 
lution is shaken with a rotary motion until the bromine imparts a 
distinct yellow color. The solution is now boiled for 7-8 minutes. 
This will expel all but a trace of bromine. To the boiling so- 
lution, which should be colorless, 15-20 drops of 5 per cent sodium 
salicylate 11 are added. The salicylic acid produced in solution will 
remove all traces of bromine, but will not affect the iodic acid. After 
boiling 1 to 2 minutes after the addition of the salicylate, the solution 
is removed from the flame, cooled, potassium iodide is added, and the 
liberated iodine titrated 12 with thiosulfate. 13 For small amounts of 



"This is best prepared by dissolving pure salicylic acid in sodium hydroxide. 

"Hunter recommends a clear 0.5 per cent solution of arrowroot starch for 
an indicator in finishing the titration. A 0.5 per cent, solution of Kahlbaum's 
soluble starch also furnishes a sensitive indicator for this work. 

I3 The most convenient strength of sodium thiosulfate for amounts of iodine 
ranging from 0.5 to 5.0 gm. is n/ 200 . This is not a stable solution, and must be 
frequently restandardized. A convenient method is to prepare a solution of 
potassium acid iodate which is equivalent to a known weight of iodine. The 
strength of any sample of thiosulfate is readily found by titrating the iodine 
liberated by the acid iodate solution, which retains its strength indefinitely. 
The iodine equivalent of the potassium iodate is found as follows: Prepare 
an N/ 10 solution of potassium acid iodate KIO3.HIO3 by dissolving 3.249 gm. of 
the salt in 1 liter of water. This solution, diluted 20 times, will be approxi- 
mately N/„ 00 . Dissolve a known weight of pure iodine (approximately 1 gm.) 
in 1 liter of water containing 1 to 2 gm. of sodium hydroxide. Dilute this ten 
times. 1 c.c. of this solution will contain 1 mg. of iodine. Measure 25 c.c. of this 
solution into a 500 c.c. flask, and dilute to 200 c.c. ; add 5 c.c. of 50 per cent 
phosphoric acid and a few drops of bromine ; boil out the bromine ; add 15 to 
20 drops of 5 per cent sodium salicylate, cool, add potassium iodide, and titrate 
the liberated iodine with approximately n/, 00 thiosulfate. This will establish 
the relation between "original iodine" and the N/„ 00 thiosulfate, and from this 



284 ST. LUKE'S HOSPITAL REPORTS 

iodine, from to 2-3 mg., this method will furnish very satis- 
factory results. It is imperative to have reagents of known purity. 
Potassium chlorate, as purchased in the open market, is often con- 
taminated with a small amount of iodide. For our work Merck's 
reagent potassium chlorate gave no traces of iodine, but all of the ordi- 
nary grades of this salt contained a small amount. The zinc must be 
free from arsenic and antimony. A blank should be made, using some 
organic substance, free from iodine. If there is no iodine in any of 
the reagents used, there should result a perfect blank. As little as 
.005 mg. of original iodine can be detected by this method. 

Some results showing that there is no loss of iodine by this method 
of fusion are as follows: 1.5 mg. of iodine, in the form of potassium 
iodide, was added to 15 gm. of the fusion mixture containing 1 gram 
of organic matter (Witte peptone). The fusions were carried out 
with a flame from an 8-inch Meker burner maintained as hot as pos- 
sible, the crucible being surrounded with an asbestos collar, as de- 
scribed above. The length of time of heating, after addition of the 
zinc, was 2 minutes. 

After the fusion the iodine was determined as above. 



Time of c.e. sodium 

heating thiosulfate used Iodine found 

3 minutes 12.71 1.50 mgm. 

6 " 12.75 1.51 mgm. 

9 " 12.70 1.50 mgm. 

12 " 12.75 1.51 mgm. 

15 " 12.72 1.50 mgm. 



Some other results obtained by heating in the first stage of the 
fusion for 3 minutes and after addition of the zinc for the indicated 
times, are: 



the iodine equivalent of the potassium acid iodate can be found by adding 
a known volume of the acid iodate to 150 c.c. of water containing potassium 
iodide and 5 c.c. of 50 per cent phosphoric acid. When a small amount of 
iodic acid is in a solution wbich contains but a small amount of salts, the 
reaction with potassium iodide is retarded, and the end point of the titration 
with thiosulfate is uncertain. The addition of 5 to 10 gm. of sodium chloride 
to such a solution accelerates the liberation of iodine and makes the end point 
sharp and accurate. 



THE DETERMINATION OF IODINE 285 

Lgth. of heating 

after addition c.c. sodium 

of zinc thiosulfate used Iodine found 

2 minutes 12.71 1.50 mgm. 

4 " 12.80 1.51 mgm. 

6 " 12.68 1.50 mgm. 

8 " 12.80 1.51 mgm. 

10 " 12.58 1.49 mgm. 

These results show that there is no appreciable loss of iodine even 
when the length of time of the fusion is prolonged to 15 minutes. 

In the determination of iodine by this method, where more than 
3-4 mg. are present, the best results are obtained by acidify- 
ing with 20 c.c. of 85 per cent phosphoric and then oxidizing with 
sodium hypochlorite. After boiling for 10-12 minutes, the sodium 
salicylate is added, as described above for bromine. 

When the hypochlorite is added to the acid solution the conditions 
are as unfavorable as possible for the formation of chloric acid, and 
with a comparatively large amount of iodine present, no appreciable 
error results from this source. However, the addition of an excess of 
hypochlorite should be avoided. Bromine and sodium hypochlorite 
should not be added together, as traces of iodine are liberated by such 
a solution even after prolonged boiling. 

Hunter showed that iodine in organic combination, as well as in 
inorganic combination, is retained and converted into an iodide with- 
out loss by an alkaline fusion mixture. The original form of com- 
bination does not appear to affect the accuracy of the determination. 

The following results were obtained by measuring a solution con- 
taining the indicated weights of iodine into nickel crucibles. The 
water was evaporated off, 15 gm. of the fusion mixture containing 1 
gm. of Witte peptone were added, and the determination made as de- 
scribed above. The iodine solutions were made by dissolving pure 
iodine in sodium hydroxide, and diluting the solution to convenient 
strength for measuring the iodine. 

Iodine taken c.c. thiosul- Iodine found Error Error 



Mg. 


fate used 


Mg. 


Mg. 


Per cent 


4.079 


39.85 


4.072 


—.007 


—0.17 


4.079 


39.65 


4.052 


—.027 


—0.66 


3.059 


29.88 


3.054 


—.005 


—0.16 


3.059 


29.85 


3.05 


—.009 


—0.29 


2.039 


35.1 


2.029 


—.01 


—0.49 


2.039 


35.1 


2.029 


—.01 


—0.49 



286 



ST. LUKE'S HOSPITAL REPORTS 



Iodine taken 


c.c. thiosul- 


Iodine found 


Error 


Error 


Mg. 


fate used 


Mg. 


Mg. 


Per cent 


1.02 


17.5 


1.011 


—.009 


—0.89 


1.02 


17.35 


1.003 


—.017 


—1.66 


0.714 


24.40 


0.717 


+ .003 


+ 0.42 


0.714 


24.80 


0.729 


+ .015 


+ 2.10 


0.510 


17.27 


0.510 








0.510 


17.85 


0.525 


+ .015 


+ 2.9 


0.306 


8.45 


0.301 


—.005 


—1.6 


0.306 


8.51 


0.303 


—.003 


—0.98 


0.102 


2.60 


0.093 


—.009 


—0.88 


0.102 


2.60 


0.093 


—.009 


—0.88 


0.051 


4.20 


0.044 


—.007 


—13.00 


0.051 


3.90 


0.041 


—.010 


—20.00 


0.031 


2.90 


0.030 


—.001 


—3.2 


0.031 


2.80 


0.029 


—.002 


—6.6 


















These results show that the method is accurate to within .02 mg. 
up to 3 or 4 mg. When used for a qualitative test for the presence 
of iodine, the method is especially valuable, as the use of bromine and 
salicylic acid assures a perfect blank in the absence of iodine. 

Three samples of desiccated thyroid gland, kindly furnished by 
Parke, Davis & Company, when analyzed by this method, gave the 

following results: 

Iodine found per 

c.c. thiosul- gram of substance 

fate used Mg. 

Sample 1 19.25 1.813 

19.28 1.816 

Sample 2 19.77 1.862 

19.77 1.862 

Sample 3 18.00 1.696 

18.25 1.719 

18.35 1.728 

I wish to express my appreciation to Mr. A. W. Thomas for assist- 
ance during the course of this investigation. 

SUMMARY. 



This paper on the determination of iodine establishes the conditions 
for the determination of iodine — 

First. — "When present as a soluble iodide or in the uncombined 
form. 



THE DETERMINATION OF IODINE 287 

Second. — When present with bromine, bromides and chlorides. 

Third. — When present with interfering compounds, as copper, sil- 
ver, mercury, nitrites, etc. 

Fourth. — When in organic combination. 

Fifth. — When present in small amounts, special reference being 
given to the determination of the iodine content of the thyroid gland. 



A NEW METHOD FOR THE DETERMINATION OF THE 
REDUCING SUGARS.* 

E. C. Kendall, Ph.D. 

In the study of velocity of amylolytie action it became desirable 
to determine with the greatest possible accuracy the reducing sugars 
resulting from the digestion of starch. This led to the following study 
of some modifications of Fehling's reagent with a view to establishing 
the optimum medium and conditions for a gravimetric method of de- 
termining reducing power. 

Benedict 1 and others have pointed out the fact that glucose is more 
readily destroyed with sodium hydroxide than with sodium carbonate, 
and that larger amounts of copper are reduced by the same weight of 
sugar if sodium carbonate is used in place of sodium hydroxide. A 
comparison of the results obtained with three of the more common 
methods and a copper solution where the sodium hydroxide is replaced 
with sodium carbonate follows. 

50 mg. of glucose reduces according to : 

Munson and Na 2 CO, solution 

Defren's method Allihn's method Walker's method replacing NaOH 

89.8 mg. Cu. 98.2 mg. Cu. 102.0 mg. Cu. 147 mg. 

We thus see that the use of sodium hydroxide gives only about 
two-thirds of the amount of copper reduced which may be obtained 
with the carbonate. 

After a series of experiments with the various alkalies, it was found 
that potassium carbonate was the one best suited to furnish the alka- 
linity. As the reducing power of glucose decreases with increase in 
the volume of the solution, it is necessary to have the volume of the 
solutions containing the copper and alkali which are added to the 

♦Reprinted from tbe Journal of the American Chemical Society, Vol. 
XXXIV, No. 3, March, 1912. 

'J. Biol. Chem., 3, 101 (1907) ; 5, 485 (1908). 

288 



DETERMINATION OF REDUCING SUGARS 289 

sugar solution as small as possible. Potassium carbonate is better than 
sodium carbonate, being much more soluble and having a slight ad- 
vantage in giving more copper reduced for the same weight of glucose. 
Some experiments showing the relation between these two carbonates 
are as follows : 

50 mg. of glucose gave with 

5 g. sodium carbonate, 129.8 mg. copper. 
10 g. sodium carbonate, 133.3 mg. copper. 

15 g. sodium carbonate, 133.3 mg. copper. 

All conditions being the same with 

12 g. potassium carbonate, 140.4 mg. copper. 
14 g. potassium carbonate, 142.8 mg. copper. 

16 g. potassium carbonate, 140.4 mg. copper. 

Having found that potassium carbonate was best suited to furnish 
the alkalinity to the copper solution, it still remained to determine 
whether a better medium than Rochelle salts could be found to hold 
the copper in solution. 

Some results according to Munson and Walker's method showed 
that unless the spontaneous reducing power of the alkaline tartrate 
solution is determined and allowed for, the results obtained will be 
considerably too high. Some results we obtained, using the method of 
Munson and Walker, but not allowing for the reducing power of the 
tartrate solution, are : 

Sugar equivalent 

Sugar taken Copper found given in table 

60 126.5 62.4 

60 124.6 61.4 

100 203.0 102.5 

100 202.7 102.3 

In their original article 2 Munson and Walker give a series of figures 
showing the reducing power of their alkaline tartrate solution from 
day to day during the course of the investigation. These results 
varied from to 2.0 mg. of cuprous oxide. Apparently the reducing 
power of the alkaline tartrate solution varies with different samples 
of Rochelle salts and it is imperative to make some correction for all 
samples which we have examined. 

The amount of copper reduced by the alkaline tartrate seems to be 

'This Journal, 28, 663 ; 29, 541. 



290 ST. LUKE'S HOSPITAL REPORTS 

much greater when the reduction takes place in a bath of boiling water 
than it does when the solution is heated for a short time over the flame 
as in Munson and Walker's method. By heating for 20 minutes in a 
bath of boiling water 50 c.c. of the mixed Defren solution in a total 
volume of 150 c.c. may reduce as much as 7 mg. of copper. Provided 
the reduction was caused by an impurity in the tartrate it would be 
possible to free the solutions from such impurities by treating the al- 
kaline tartrate with a copper solution, reduce by heating in a bath of 
boiling water, filter, and use the resulting solution which would have 
no reducing power of its own. This was tried and it was then found 
that when such a solution was heated again in the boiling water a 
second reduction, as large as the first, took place. If the cuprous 
oxide was then filtered off and the solution again heated, a third re- 
duction took place. Since this showed that the reduction is due to the 
tartrate itself, and that a previous reduction is not capable of removing 
the source of error, it seemed imperative to find some medium other 
than Rochelle salts for keeping the copper in solution. 

Many compounds have been proposed for this purpose, among 
which may be mentioned the bicarbonate solution of Soldaini 8 and the 
citrate solution proposed by Benedict. 4 In Benedict's volumetric 
method for the determination of sugar the disappearance of the blue 
color is taken as the end point of the titration and this method allows 
of an accurate determination of the sugar. Experiments were there- 
fore made to see if Benedict's citrate solution could be adapted to a 
gravimetric method. It was then found that marked changes in the 
reducing powers of the sugars followed changes in concentration of 
the sodium carbonate and citrate. 

Thus, using 50 mg. of glucose and 2 g. of copper sulfate in a vol- 
ume of 150 c.c, the following weights of copper, expressed in milli- 
grams, were obtained under the conditions as given below, when heated 
for 20 minutes in a bath of boiling water : 

Sodium carbonate Sodium carbonate Sodium carbonate 



Sodium citrate 


5 grams 


10 grams 


15 grams 


Grams 


Mg. 


Mg. 


Mg. 


5 


116.5 


134.1 


144.2 


10 


100.0 


117.3 


127.1 


15 


89.3 


107.9 


122.0 


20 


65.3 


101.8 


117.8 



"Gaz. chim. Ital., 6, 322. 

4 J. Biol. Ctaem., 5, 485 (1908). 



DETERMINATION OF REDUCING SUGARS 291 

The change in the reducing power of sugar is explained only in 
part by assuming that the citrate solution dissolved the reduced cu- 
prous oxide. This was shown by placing 150 mg. of Kahlbaum's cu- 
prous oxide in each of four flasks and heating it under identical con- 
ditions of volume, time, and concentration of solution as in the above 
experiments. Oxidation of the cuprous oxide during the heating was 
prevented by displacing the air in the flask with illuminating gas and 
closing the flask with a two-hole stopper. 

Determination of the copper content of 150 mg. of the cuprous 
oxide used showed on duplicate determination 125.6 and 126.1 mg. 
of copper, average 125.9 mg. All conditions being the same as above, 
the following weights of cuprous oxide were recovered after heating 
for 20 minutes: 

Sodium carbonate Sodium carbonate 

Sodium citrate 5 grams 15 grams 

Grams Mg. Mg. 

5 125.2 

10 123.3 122.4 

15 120.2 122.4 

20 118.3 122.1 

As 20 g. of sodium citrate in the presence of 5 g. of sodium car- 
bonate could dissolve but 7.6 mg. of cuprous oxide the low results 
obtained with the sugar must be due to a depression of the reducing 
power of the sugar by the citrate. The results of other experiments 
in which the weights of sugar varied showed that a citrate solution 
does not furnish a satisfactory solution in a gravimetric method. 

As the spontaneous reduction of Rochelle salts and the depression 
and variations caused in the reducing power of sugar by sodium 
citrate are serious objections to these two salts, further work was 
done to find some other agent for holding the copper in solution. 

Theoretically, any organic compound having a carboxyl and alcohol 
group is capable of holding the copper in solution in an alkaline mix- 
ture. Glycerol and mannite have also been suggested as possible 
agents, but they do not furnish a convenient solution with which to 
work. Lactic acid will hold the copper in solution, but the reducing 
power of sugar is but slight in such a solution. 

Among a number of organic compounds which were tried, salicylic 
acid was found to be one which will furnish a medium for the re- 
duction of sugar, but which has no reducing power of its own, and 
will not dissolve the cuprous oxide. 



292 ST. LUKE'S HOSPITAL REPORTS 

An alkaline salicylate solution replacing the alkaline tartrate 
showed no reduction of copper when heated in a bath of boiling 
water for 7 hours, and the following results show that there is no ap- 
preciable change in reducing power with small changes in concen- 
tration of the salicylic acid. 

50 mg. glucose. 5 grams sodium carbonate in 150 c.c. volume. 

3 grams salicylic acid, 125.7 mg. copper. 

4 grams salicylic acid, 126.0 mg. copper. 

5 grams salicylic acid, 125.7 mg. copper. 

6 grams salicylic acid, 124.8 mg. copper. 

Further experiments showed that with the other reducing sugars, 
maltose, lactose, and invert sugar, the alkaline salicylate solution fur- 
nishes a satisfactory medium for the reduction of the copper. 

It now remained to determine what weights of copper, potassium 
carbonate and salicylic acid give the optimum conditions for the re- 
duction of the copper. 

In Munson and Walker's conditions, 1.858 grams of copper sulfate 
(crystalline) are used per determination, the largest weight of copper 
reduced being 435.3 mg. While larger amounts of copper give greater 
reducing powers to the sugars, it was decided to use two grams of 
copper sulfate (crystalline) per determination and limit the reduction 
to 450 mg. of copper. 

The weights of potassium carbonate and salicylic acid which give 
the optimum conditions for maltose were determined and these weights 
were used for the determination of the reducing power of the other 
sugars. 

The effect of varying amounts of potassium carbonate and salicylic 
acid is shown in the following table. The volume was 140 c.c. and 
2 g. of copper sulfate were present: 

Sugar Salicylic Potassium carbonate 



maltose 


acid 


r 


A 


i 


Mg. 


Grams 


12 g. 


14 g. 


15 g. 


100 


4 


151.7 


153.8 


154.9 


100 


5 


151.0 


157.1 


155.0 


100 


6 


149.1 


154.6 


154.8 


100 


7 


135.7 


150.4 


154.9 



These and other determinations showed that 15 grams of potassium 
carbonate, 5 grams of salicylic acid, and 2 grams of copper sulfate in 
a total volume of 140 c.c. give satisfactory conditions for the deter- 



DETERMINATION OF REDUCING SUGARS 293 

urination of maltose. The least volume of water which will conve- 
niently dissolve the copper sulfate is 15 c.c. and the least volume for 
the 15 grams of potassium carbonate is 25 c.c. While it would be 
possible to make one solution of the three compounds, it was found 
that both copper and potassium salicylate are so slightly soluble that 
the volume of such a solution would be too great to give satisfactory 
results. The potassium carbonate and copper sulfate are therefore 
dissolved in water and added separately to the sugar solution while 
the salicylic acid is added in the dry condition. 

In regard to the method of heating, the following experiments were 
carried out to determine whether or not any cuprous oxide was lost 
during the heating by surface oxidation: 

150 mg. of Kahlbaum's cuprous oxide were placed in each of four 
flasks, 15 grams of potassium carbonate, 2 grams of copper sulfate and 
5 grams of salicylic acid were added in a volume of 140 c.c. 

The weight of copper in 150 mg. of the cuprous oxide used was 
found to be 125.9 mg. The weights of copper recovered from the 
four flasks after the treatment indicated below were as follows: 

1. Solution boiled over free flame under conditions of Munson and 
Walker, 124.5 mg. copper recovered. 

2. Solution heated 20 minutes in bath of boiling water, 126.3 mg. 
copper recovered. 

3. Solution heated 20 minutes in bath of boiling water with surface 
covered with toluene, 125.7 mg. copper recovered. 

4. Solution heated 20 minutes in bath of boiling water, air above 
solution being displaced with illuminating gas, 126.3 mg. copper re- 
covered. 

These results showed that there is no appreciable loss of cuprous 
oxide due to surface oxidation when the heating is continued for 20 
minutes in the boiling water. 

The two methods of heating which have been used for the reduction 
of copper with sugar are by heating over a free flame or in a bath of 
boiling water. In choosing between these two methods, ease of oper- 
ation, time required, and accuracy of the results obtained were the 
factors considered. 

The following results bear on this point: 

The conditions of the solutions in each of the following sets were 
those found to be the optimum conditions for determining the re- 
ducing power of sugars. Volume 140 c.c, potassium carbonate 15 
grams, salicylic acid 5 grams, copper sulfate 2 grams. 



294 



ST. LUKE'S HOSPITAL REPORTS 



HEATING IN BATH OF BOILING WATER 





Glucose, 


Invert sugar, 


Lactose, 


Maltose, 


Time, 


50 mg. 




50 mg. 




100 mg. 


100 mg. 


min. 


Mg. Cu. 




Mg. Cu 




Mg. Cu. 


Mg. Cu. 


10 


132.7 




142.4 




123.6 


124.8 


15 


145.1 




152.5 




144.5 


144.8 


20 


149.8 




154.7 




154.4 


153.1 


25 


150.1 




157.4 




161.1 


158.5 


30 


155.0 




162.9 




165.4 


163.3 


40 


157.1 




164.9 




171.6 


167.9 


50 


159.9 




166.3 




176.2 


172.2 






HEATING OVEB FLAMI 






Total time Time of 




Glucose, 




Lactose, 


of heating, boiling, 




50 mg. 




100 mg. 


min. 




min. 




Mg. Cu. 




Mg. Cu. 


6 




2 




112.2 




103.0 


8 




4 




134.1 




132.8 


9 




5 




137.1 




139.0 


12 




8 




143.8 




154.1 


14 




10 




143.0 




161.1 


16 




12 




148.3 




163.6 


18 




14 




150.4 




167.3 


20 




16 




153.4 




169.4 



The figures in the first line of the last table above give the weights 
of copper reduced under the conditions of Munson and Walker. It 
is apparent that the reduction under these conditions is far from 
complete and that the speed of reaction at this point is too great to 
allow of an accurate determination of reducing power. The reason 
for the incomplete reduction after two minutes ' boiling is undoubtedly 
due to the slower reaction of the carbonate-salicylate solution than 
of the hydroxide-tartrate solution. 

When the determinations of reducing power are done in sets of 
four or more time is saved per determination by making the time of 
heating as short as possible. However, it is evident that at least 
12 minutes of boiling over a flame are required. When the time of 
heating is limited to 12 minutes it is impossible to filter one set while 
the following set is being heated, but if the time of heating be ex- 
tended it is possible to give one's entire attention to filtering the re- 
duced copper and hence there is no actual loss of time per determi- 
nation. 

To boil a solution over a flame for 12 to 16 minutes requires more 



DETERMINATION OF REDUCING SUGARS 295 

or less attention to maintain uniform conditions, but it is an easy 
matter to duplicate conditions of heating in a bath of boiling water 
and no attention is required during the heating. Furthermore, it 
was found that the results obtained by heating in boiling water are 
more accurate than those obtained by boiling the solution. After 
20 minutes' heating in boiling water the reaction is nearly complete 
for glucose and invert sugar and there is only a slow rate of reduction 
for lactose and maltose. As heating beyond 20 minutes would mean 
a needless expenditure of time, it was decided to limit the reduction 
for all of the sugars to that obtained during 20 minutes' heating in 
boiling water. 

Although the salicylic acid is employed in the alkaline solution and 
must, therefore, exist as potassium salicylate, it was found impossible 
to replace the acid with sodium salicylate and obtain the same re- 
ducing power for maltose. 

The following results show the difference between the free acid and 
the sodium salt: 



Grams 


Sodium salicylate 


Salicylic acid 


3 


117.4 


141.3 


4 


126.0 


143.1 


5 


131.9 


148.4 


6 


136.2 


148.7 



The volume was 125 c.c, 2 g. copper sulfate, 11.5 g. potassium car- 
bonate, and 100 mg. of maltose being present. The figures are milli- 
grams of copper reduced. 

When the salicylic acid and sodium salicylate were kept constant 
and the potassium carbonate varied, the following results were ob- 
tained : 

Potassium Sodium salicylate Salicylic acid 



carbonate 


3 grams 


3 grams 


Grams 


Mg. Cu. 


Mg. Cu. 


15 


123.1 


145.6 


18 


125.7 


146.8 


21 


130.4 


148.1 


24 


135.8 


151.9 



The volume was 125 c.c, 2 g. of copper sulfate and 100 mg. maltose 
were used. 

Another series where more salicylic acid and sodium salicylate 
were used gave the following results : 



296 



ST. LUKE'S HOSPITAL REPORTS 



Potassium 
carbonate 


Sodium salicylate 




Grams 


Grams 


Copper 


15 


6 


138.3 


18 


6 


142.1 


21 


6 


144.3 


24 


6 


147.8 


Potassium 
carbonate 


Salicylic acid 




Grams 


Grams 


Copper 


12 


6 


148.1 


15 


6 


152.6 


18 


6 


157.0 


21 


6 


158.3 



Although it would seem to make no difference when the sugar was 
added to the solution of potassium-copper salicylate, experiment 
showed that it is necessary to add the copper to the solution and not 
vice versa. A series where 15 g. of potassium carbonate and 5 g. of 
salicylic acid were used, and 100 mg. of maltose were added to this 
solution gave 152.6, 146.2, 149.1, and 156.2 mg. of copper reduced. 
Under identical conditions, but where the copper solution was added 
to the sugar, the following weights of copper were obtained: 154.9, 
155.0, 154.8, 154.9. 

The effect of mixing the sugar and alkaline copper solutions and 
allowing to stand in the cold is shown by the following results: To 
four flasks, each containing 100 c.c. of water, 100 mg. of lactose and 
25 c.c. of copper sulfate (2 grams) were added. At intervals of 5 
minutes, 12 grams of potassium carbonate and 3 grams of salicylic 
acid were added to the 4 flasks in succession. The flask to which the 
potassium carbonate and salicylic acid was first added would have 
stood 15 minutes before the mixture had been added to the fourth 
flask. As soon as the fourth flask was ready they were all placed in 
the boiling water, and allowed to remain 20 minutes; the following 
weights of copper were obtained : 

Solution stood in the cold 15 min., 149.8 

Solution stood in the cold 10 min., 147.4 

Solution stood in the cold 5 min., 146.3 

Solution stood in the cold min., 146.5 

These results show that the sugar can stand in the alkaline copper 
solution for 5-6 minutes in the cold without any appreciable change, 
but that a slight reduction will occur if they are allowed to stand 



DETERMINATION OF REDUCING SUGARS 297 

10-15 minutes. In practice 2-3 minutes is all that is needed to dis- 
solve the salicylic acid and prepare the solutions for the boiling water. 
The temperature at which the solutions are added to the boiling 
water is without appreciable influence between 18° and 50°. Four 
solutions, each containing 12 g. potassium carbonate, 3 g. salicylic 
acid, 2 g. copper sulfate, and 100 mg. lactose, when placed in the boil- 
ing water at the indicated temperature gave the following weights of 
copper reduced : 

18°, 150.4 mg. copper; 30°, 150.7 mg. copper; 40°, 150.7 mg. copper; 50°, 
151.5 mg. copper. 

It is essential to have the boiling water heated with a flame large 
enough to cause the water to begin boiling within 1.5-2 minutes after 
the addition of the flasks containing the sugar-copper solutions. 

Two flasks, containing 12 g. of potassium carbonate, 3 g. of sali- 
cylic acid, 2 g. of copper sulfate, and 120 mg. of lactose in 125 c.c, 
were placed in the boiling water with a flame under the bath, which 
caused the water to boil within 1.5-2 minutes after the flasks were 
placed in the bath. The copper reduced at the end of 20 minutes was 
175.5 and 176.3 mg. Two other flasks containing identical solutions 
were placed in the boiling water with a flame under the bath which 
caused the water to boil in 5-6 minutes after the addition of the flasks. 
After 20 minutes from the time the flasks were placed in the water 
the copper reduced was 167.9 and 171.8 mg., showing lower and ir- 
regular results. 

In order to show the variations caused by slight differences in the 
weights of potassium carbonate and salicylic acid added, the following 
series of determinations were made under identical conditions of time 
and volume. The volume was 140 c.c. and time 20 minutes : 

Potassium Salicylic Invert 



irbonate 


acid 


Glucose 


sugar 


Lactose 


Maltose 


Grams 


Grams 


50 mg. 


50 mg. 


100 mg. 


100 mg. 


15 


4 


148.9 


155.2 


160.0 


154.9 


15 


5 


149.2 


155.7 


157.2 


155.0 


15 


6 




156.7 


154.9 


154.9 


15 


7 


150.0 


158.0 


151.4 


154.9 


13 


5 


151.4 




152.9 


153.0 


14 


5 


151.4 


158.3 


154.5 


154.6 


15 


5 


149.4 


155.7 


157.2 


155.0 


16 


5 


149.4 


156.1 


156.9 


156.3 


17 


5 


147.3 


155.5 


160.1 


158.4 



298 ST. LUKE'S HOSPITAL REPORTS 

These results show that glucose, maltose, aud invert sugar vary but 
slightly for differences in amounts of potassium carbonate and sali- 
cylic acid present and that lactose is more sensitive in this respect. 

In practical determinations of sugar, the variations in the weights 
of potassium carbonate and salicylic acid can be controlled within 
± 0.2 g. without taking any special precautions, and it is apparent that 
such a variation causes no appreciable change in the reducing power 
of any of the sugars. 

DETERMINATION OP THE COPPER REDUCED. 

The writer recently described a method for the determination of 
copper by means of the iodide method. The method described was 
devised primarily for the determination of copper obtained by the 
reduction with sugar. It differs from the original iodide method in 
that the solutions are prepared for titration in the cold, thus over- 
coming the delay caused by boiling the solution or evaporating to 
dryness. 

During the course of this investigation several hundred determina- 
tions of copper have been made by this modification of the iodide 
method, and these results show that, if the conditions prescribed are 
followed, the determination of copper can be made by this method 
with great accuracy. Irrespective of the way the reduced copper is 
determined it has to be removed from its filter, and the most conve- 
nient way to do this is to dissolve it in nitric acid. The iodide method 
allows of the accurate determination of the copper thus dissolved, 
hence doing away with drying and weighing, which is time-consuming 
and laborious. 

The cuprous oxide reduced by the sugar is filtered on a glass fun- 
nel such as is usually employed to hold a Gooch crucible. The filter 
is made by placing a perforated porcelain disk in the bottom of the 
funnel and making an asbestos felt 6 to 8 mm. in thickness. A porce- 
lain disk should be used to hold the asbestos, as glass wool retains 
traces of alkaline copper solution. After the solution has been filtered 
with suction and washed with hot water, the funnel and rubber stop- 
per are removed from the suction flask, washed free from any copper 
solution which may adhere to the outside, and placed on a 350 c.c. 
suction flask. If the stopper does not fit, the top of the flask is ground 
smooth on a carborundum hone so that when suction is applied it will 
hold the stopper down tightly over the mouth. Before the suction is 
applied to the flask the cuprous oxide is dissolved in not less than 10 



DETERMINATION OF REDUCING SUGARS 299 

c.c. of hot nitric acid (1 part of acid to 3 of water). It is imperative 
to have the nitric acid hot and it should be contained in a wash bottle 
which delivers a small stream. The flask in which the reduction takes 
place and the sides of the funnel are washed with the hot acid and 
then the asbestos is stirred up by the jet from the wash bottle. It is 
best not to have a porcelain disk on the surface of the asbestos. The 
hot nitric acid will dissolve only a trace of nitrous oxide, but if cold 
nitric acid is used large amounts of nitrous acid will be dissolved, 
which will prevent the accurate determination of the copper. When 
all of the cuprous oxide has been dissolved the suction is applied and 
the funnel is washed with several additions of small amounts of water 
— not more than 10-12 c.c. at a time. The wash water is sucked 
through each time before more is added. All of the copper, when 
washed in this way, can be removed with 40-50 c.c. of wash water. 
The copper in solution may now be determined as described in the 
method. 5 

PREPARATION AND ANALYSIS OP THE SUGARS USED. 

The four sugars used to determine the relation between sugar and 
copper given in the table below were prepared and analyzed as fol- 
lows: 

The glucose of highest purity, furnished by Merck & Co., when 
analyzed for moisture and rotating power, showed 0.16 per cent of 
moisture and a specific rotating power of 52.68°. As the specific ro- 
tating power was in accordance with that given by Tollens for pure 
glucose no further purification was considered necessary. 

The sucrose was prepared from Kahlbaum's C. P. saccharose by 
the method outlined by the International Commission for the Unifi- 
cation of Sugar Analysis. The sample thus prepared contained 0.13 
per cent of moisture and showed a specific rotating power of 66.5 Y 

The lactose was prepared from Kahlbaum's crystallized lactose by 
dissolving in boiling water, filtering, and allowing the lactose to crys- 
tallize for 7 days from this solution. These crystals were dried in a 
vacuum over sulfuric acid for three days, ground into a powder, and 
again dried in vacuum over sulfuric acid. The determination of 

B This Journal, 33, 1947. 

6 The sucrose was inverted essentially by the method used by Munson and 
Walker, by heating for 30 minutes in boiling water with n/ 10 HC1, using 20 c.c. 
for every 100 c.c. final volume. The solution was barely neutralized with 
N/ 10 sodium hydroxide, cooled, and filled at 20° to the mark of graduation. 



300 ST. LUKE'S HOSPITAL REPORTS 

moisture showed 5.62 per cent of water. One molecule of water, cor- 
responding to the formula C^H^OnH-jO, requires 5.0 per cent of 
water, therefore the sample thus prepared contained 0.62 per cent ex- 
cess water calculated as lactose hydrate. Its specific rotating power 
calculated as C 12 H„ 2 ]1 H 2 was 52.51°. 

The maltose was prepared by letting barley diastase act on soluble 
starch as described by Baker and Day 7 and Baker. 8 The maltose thus 
prepared was dried in an electric oven at 70-80° for 15-18 hours, and 
was then ground and passed through a 60-mesh sieve. The moisture 
determination showed 5.33 per cent of water. As maltose hydrate, 
C^H^On-HaO, requires 5 per cent of water there was present 0.33 
per cent excess water. The specific rotating power was 137.3°. 

The rotating power of all preparations was determined with so- 
dium light, using a 4 decimeter tube in a Schmidt and Haensch polari- 
scope at 20°. The solutions were 10 per cent of sugar, except for 
maltose, which was 5 per cent. The solutions, except for sucrose, 
were allowed to stand 24 hours at room temperature to destroy the 
multirotation. 

The water content of all preparations were determined as follows : 
Two grams of the sample in a small weighing bottle was placed in the 
bottom of a 4-inch desiccator which had a suction outlet in the lid. 
Around the weighing bottle was placed a wire gauze collar about 1.75 
inches in diameter. This wire gauze supported a Petri dish of 3 
inches diameter which contained phosphorus pentoxide. A second 
Petri dish of almost the same diameter as the desiccator was supported 
above the first Petri dish by three wire supports at a distance of 0.5 
inch above the lower Petri dish. This top Petri dish acted as a cover 
and prevented the phosphorus pentoxide from dusting when the 
suction was released. After placing the cover on the desiccator it 
was placed inside an electric oven and connected with stout suction 
hose to a Gaede pump. The temperature of the oven was kept for 
lactose at 130°, maltose 110°, sucrose and glucose 100°, for 4-5 hours. 
The suction was maintained during the entire time of heating. At 
intervals of one hour the weighing bottle was taken out of the desic- 
cator and weighed. When heating for one hour produced a change 
of less than 0.5 mg. the heating was discontinued. Duplicate deter- 
minations were made in all cases. 



7 Analyst, 33, 393 (1908). 
*J. Chem. Soc, 1902, 1177. 



DETERMINATION OF REDUCING SUGARS 301 



DETERMINATION OF RELATION BETWEEN SUGAR AND COPPER. 

For maltose and lactose the sugar was weighed out in such quan- 
tities as to make 5 mg. per e.c. of solution, allowance being made for 
the presence of the water; the weights of sugar were calculated as 
maltose and lactose hydrate, C 12 H 22 11 .H 2 0. 

For invert sugar and glucose, solutions were made which contained 
2.5 mg. of sugar calculated as C 6 H 12 6 . 

The temperature of graduation of both flasks and burets was 20°. 

THE REDUCING POWER OF THE SUGARS. 

The reducing power of the sugars was determined as follows : The 
varying weights of sugar as indicated below were measured into 200 
c.c. Erlenmeyer flasks and the volume in each case made up to 100 c.c. 
with distilled water. Five grams of salicylic acid were now added 
to each of 4 flasks containing the sugar to be determined. Fifteen 
c.c. 9 of copper sulfate solution and then 25 c.c. potassium carbonate 10 
solution were added to each of the flasks without any agitation of 
the solution. It was found necessary to observe this order for the 
addition of the reagents. The flasks were then shaken with a rotary 
motion. The precipitate of copper carbonate dissolved, forming a 
dark green solution. As soon as the salicylic acid dissolved the four 
flasks were put in a holder and placed in a bath of boiling water. 11 

The copper sulfate solution is prepared by dissolving 133.33 grams of 
CuS0 4 .5H 2 per liter of water ; 15 c.c. of such a solution contains 2 grams of 
copper sulfate. 

10 The potassium carbonate solution contains 600 g. of anhydrous potassium 
carbonate per liter; 25 c.c. of this solution contains 15 g. of potassium car- 
bonate. As potassium carbonate is hygroscopic, it is necessary to drive off all 
water before making up the solution. This is done by heating the carbonate 
for 3 to 4 hours at a temperature from 190° to 200°. A sample of the salt thus 
treated, when heated in a small test tube, should not give any evidence of 
liberation of water. The carbonate solution should be made up in a liter or 
other size graduated flask, and should be diluted almost to the proper volume, 
well mixed, and then adjusted to the mark of graduation. 

"The water bath used during this investigation was one 10 inches in diame- 
ter and &/o inches deep. It contained 4 liters of water. The level of the water 
could be maintained constant by using the ordinary constant water-level bath, 
or by means of a syphon acting between the water bath and a reservoir of 
water of constant level. The syphon, for constant use, must have a T or Y 
tube inserted at its highest point. A 20 c.c. pipet closed at one end with 
rubber hose and pinchcock is connected with the T tube. To start the syphon, 



302 ST. LUKE'S HOSPITAL REPORTS 

The flame under the bath must be of such size that boiling begins 
within 1.5 to 2 minutes after addition of the flasks. At the end of 20 
minutes from the time the flasks were placed in the bath the solutions 
were filtered and the copper determined as described above. 

both ends are placed under water and (the pinchcock being open) the air is 
withdrawn from the pipet. When the pipet is full of water the pinchcock 
is closed. Any bubbles of air liberated from the water in the tube of the 
syphon will rise to the highest point of the tube, and will there be caught in 
the pipet, displacing the water. Should the pipet become filled with air, 
the syphon may be re-established by again withdrawing the air through the 
rubber tube and pinchcock. The end of the syphon which is in the water bath 
must have a small opening (about Ys inch). If a large opening is used, the 
the water, when boiling, may syphon out of the bath. The diameter of the 
rest of the syphon may be of any sized tubing. 

The flame under the water bath was supplied by one large-sized Fletcher 
and two Bunsen burners. The water should be boiling vigorously when the 
flasks are placed in the water, and all of the flames should be burning. As 
soon as the water has begun to boil, after the addition of the flasks (which 
should be in less than two minutes), the two Bunsen burners are turned out, 
as the Fletcher burner is sufficient to maintain the boiling. 

In the practical application of this method for the determination of the 
reducing sugars, it is most convenient to make a set of 4 determinations at 
once. A rack is made to hold the 4 flasks, as follows : a brass rod ^ inch in 
diameter and 14 inches long, is erected at the center point, and perpendicular 
to a brass disk 8 inches in diameter and 3 / 32 inch thick. This disk forms the 
bottom upon which the flasks are placed. Another disk of the same size as 
the bottom one, but with a hole s / w inch in diameter, slides up and down the 
rod. Four holes 1% inches in diameter are drilled through this second disk, 
the centers of the holes being arranged symmetrically 2*4 inches from the 
center of the disk. This top disk being lifted up, the four flasks are placed 
on the bottom of the holder. When the top disk is lowered the flasks will 
pass through the four holes, and, as the opening is only sufficiently large to 
allow the neck of the flask to pass through, the flasks are held secure. A hook 
at the end of the rod is used to hang the entire holder from a support above 
the bath, at such a height that the rack sinks in the water up to the level of 
the top disk. In the bottom disk a number of %-inch holes are drilled, so that 
the rack may be placed in and removed from the water with ease. When 
the flasks are removed from the rack the solutions are filtered immediately 
on four suction flasks. 



DETERMINATION OF REDUCING SUGARS 



303 



Weight of 
sugar 



Glucose 



TABLE I. 

Weight of 
Invert sugar sugar 



Lactose 



Maltose 



mg. 
10 


1— ■■ ' 

30.4 


30.2 


30.9 


30.7 


20 


31.9 


32.1 


31.0 


30.3 


20 


60.9 


61.8 


63.2 


62.4 


40 


64.0 


62.5 


61.0 


61.3 


30 


90.2 


90.6 


94.4 


94.7 


60 


95.5 


95.2 


93.4 


92.3 


40 


120.0 


120.1 


126.5 


126.8 


80 


124.5 


125.0 


123.6 


123.6 


50 


148.1 


149.9 


157.5 


156.7 


100 


157.7 


157.7 


154.6 


154.6 


60 


176.8 


179.2 


188.2 


186.4 


120 


287.4 


286.3 


187.9 


187.2 


70 


206.1 


207.4 


5 217.5 
I 217.5 


219.7 | 
215.6 j 


140 


218.5 


217.0 


219.2 


218.5 


80 


233.8 


233.8 


5 245.3 
{ 245.6 


245.3 | 
*248.0 j 


160 


246.3 


246.7 


250.6 


250.4 


90 


261.3 


263.3 


276.1 


276.1 


180 


279.0 


278.4 


278.6 


280.1 


100 


288.0 


289.2 


302.6 


302.6 


200 


306.8 


305.9 


j 309.6 

I 310.9 

342.2 


*313.6 
*312.4 


110 


316.2 


314.7 


330.8 


330.7 


220 


338.7 


337.1 


342.2 


120 


343.1 


341.5 


359.4 


358.6 


240 


5 364.6| 

1 364.9 S 

397.3 


*363.4 


373.3 


372.9 


130 


367.7 


367.7 


385.5 


386.4 


260 


397.1 


403.2 


401.6 


140 


391.2 


393.0 


410.9 


410.9 


280 


424.9 


427.0 


431.4 j. 


431.4 
*429.4 


150 


418.5 


418.5 


438.1 


438.1 


300 


455.6 


454.3 


\ 459.4 
\ *456.2 


458.1 
*454.3 


160 


443.3 


442.1 


462.1 


460.9 

TABLE 


n. 










Glucose 


Invert sugar 


Lactose 




Maltose 


. A 




A 






A 




A 





Calcu- 
F'nd lated Error 
Mg. Mg. Mg. 

30.3 30.6 

61.4 60.9 
90.4 90.8 

120.1 120.3 
149.0 149.4 
178.0 178.1 



206.8 206.4 

233.8 234.3 

262.3 261.7 

288.6 288.8 

315.5 315.5 

342.3 341.7 



367.7 
392.1 
418.5 
442.7 



367.6 
393.0 
418.1 
442.7 



0.3 
—0.5 

0.4 

0.2 

0.4 

0.1 
—0.4 

0.5 
—0.6 

0.2 


—0.6 
—0.1 

0.9 
—0.4 





Calcu- 
lated 
Mg. 
31.43 
63.55 
95.24 



F'nd 

Mg. 

30.8 

62.8 

94.6 
126.7 
157.1 157.15 
187.3 187.37 



Error F'nd 

Mg. Mg. 

0.63 32.0 

0.75 63.3 

0.64 95.4 

126.44 —0.26 124.8 

0.05 157.7 

0.07 186.9 

217.7 217.10 —0.60 217.8 

245.5 246.33 0.83 246.5 



276.1 275.07 
302.6 303.33 
330.8 331.09 



-1.03 278.7 
0.73 306.4 
0.29 337.9 



359.0 358.35 —0.65 364.8 

386.0 385.14 —0.86 397.2 
410.9 411.43 0.53 426.0 

438.1 437.23 —0.87 455.0 
461.5 462.55 1.05 



Calcu- 
lated 
Mg. 
32.07 
63.38 
94.52 
125.48 
156.28 
186.90 
217.34 
247.60 
277.70 
307.63 
337.38 
366.95 
396.35 
425.58 
454.64 



Error 
Mg. 

0.07 

0.08 
—0.88 

0.68 
—1.42 


—0.46 

1.10 
—1.00 

1.23 
—0.52 

2.15 
—0.85 
—0.42 
—0.36 



F'nd 

Mg. 

30.6 

61.2 

92.9 

123.6 

154.6 

187.6 

218.9 

250.5 

279.4 

310.3 

342.2 

373.1 

402.4 

431.4 

458.7 



Calcu- 
lated 
Mg. 
30.2 
61.96 
93.57 
125.02 
156.32 
187.47 
218.47 
249.32 
280.04 
310.59 
341.00 
371.25 
401.35 
431.31 
461.12 



Error 

Mg. 

—0.40 

0.76 

0.67 

1.42 

1.72 

—0.13 

—0.43 

—1.18 

0.64 

0.29 

—1.20 

—1.85 

—1.05 

—0.09 

2.42 



304 ST. LUKE'S HOSPITAL REPORTS 



TABLE m. 

Dextrose Invert sugar Lactose Maltose 



50 100 50 100 100 200 100 200 

Method mg. mg. mg. mg. mg. mg. mg. mg. 

Defren 89.8 178.1 125.7 248.4 109.5 216.5 

Munson and Walker... 102.2 198.4 98.5 192.3 132.7 261.6 108.7 215.4 

Allihn 98.2 195.0 

Lehmann 101.4 190.0 

Meissl 96.0 189.2 

Soxhlet 138.3 269.6 

Wein H5.1 226.8 

Ost 165.6 294.3 170.0 298.0 167.5 331.8 

Kjeldahl 107.2 197.7 101.7 190.2 

Brown, Morris & Millar 103.0 202.7 97.5 194.1 

This method 149.3 288.7 157.0 303.3 156.3 307.6 156.3 310.6 

Using this method of procedure, the results in Table I were obtained 
for the indicated weights of sugar. All of the results which were 
obtained are given, but the ones which were not used in the calculation 
of the curve are starred: 

From these results the following equations showing the relation 
between sugar and copper were deduced by means of the method of 
least squares. 12 

In the equations X refers to weights of copper reduced, Y to 
weights of sugar reacting: 

Glucose X = — 0.17 + 3.0923 Y — 0.002026 Y» 

Invert sugar X = — 1.30 + 3.2918 Y — 0.002455 Y» 

Lactose X= 0.59 + 1.5786 Y — 0.000217 Y 1 

Maltose X = — 1.69 + 1.5988 Y — 0.000187 Y 1 

The weights of sugar given in Table I were substituted in the 
proper equation and the corresponding values of X were found. The 
differences between the values thus calculated and actually found is 
given in Table II. 

By means of the equation the copper equivalent to weights of mal- 
tose and lactose from 20 to 300 mg. were calculated for every 4 mg. of 
sugar. With glucose and invert sugar the copper equivalent for every 
2 mg. of sugar from 10 to 160 was found. This gave a series of points 
which differed by about 6 mg. of copper. These figures were changed 

U A good example of the use of this method is given in Allihn's original 
article, J. prakt. Chem., 22, 46 (1880). 



DETERMINATION OF REDUCING SUGARS 



305 



to integral weights of copper and hence decimal weights of sugar. 
The figures lying between each 6 mg. of copper were interpolated, the 
interpolations being carried to the second decimal place. The com- 
plete table giving the relation between the 4 reducing sugars and 
copper for every mg. of copper from 30 to 450 mg. is given in 
Table IV. 

A comparison of the reducing power of the sugars obtained by 
this method with that obtained with other methods in use is given in 
Table III. 

I wish to express my appreciation to Mr. A. W. Thomas for assist- 
ance during the course of this investigation. 



TABLE IV 





Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


CgH^Og 


CeH^Oa 


Ci2H 22 O n . H 2 


C^A^O 


30 


33.8 


37.6 


9.8 


9.6 


19.3 


19.9 


31 


34.9 


38.8 


10.2 


9.9 


20.0 


20.5 


32 


36.0 


40.1 


10.5 


10.2 


20.6 


21.1 


33 


37.2 


41.3 


10.8 


10.5 


21.2 


21.7 


34 


38.3 


42.6 


11.1 


10.8 


21.8 


22.4 


35 


39.4 


43.8 


11.5 


11.1 


22.5 


23.0 


36 


40.5 


« 45.1 


11.8 


11.4 


23.1 


23.6 


37 


41.7 


46.3 


12.1 


11.8 


23.7 


24.3 


38 


42.8 


47.6 


12.4 


12.1 


24.4 


24.9 


39 


43.9 


48.8 


12.8 


12.4 


25.0 


25.5 


40 


45.0 


50.1 


13.1 


12.7 


25.6 


26.1 


41 


46.2 


51.3 


13.4 


13.0 


26.3 


26.8 


42 


47.3 


52.6 


13.8 


13.3 


26.9 


27.4 


43 


48.4 


53.8 


14.1 


13.6 


27.5 


28.0 


44 


49.5 


55.1 


14.4 


13.9 


28.1 


28.7 


45 


50.7 


56.3 


14.8 


14.2 


28.8 


29.3 


46 


51.8 


' 57.6 


15.1 


14.5 


29.4 


29.9 


47 


52.9 


58.8 


15.4 


14.8 


30.0 


30.6 


48 


54.0 


60.1 


15.7 


15.2 


30.6 


31.2 


49 


55.2 


61.3 


16.1 


15.5 


31.3 


31.8 


50 


56.3 


62.6 


16.4 


15.8 


31.9 


32.4 


51 


57.4 


63.8 


16.7 


16.1 


32.5 


33.1 


52 


58.5 


65.1 


17.1 


16.4 


33.2 


33.7 


53 


59.7 


66.3 


17.4 


16.7 


33.8 


34.3 


54 


60.8 


67.6 


17.7 


17.0 


34.4 


35.0 


55 


61.9 


68.8 


18.1 


17.3 


35.0 


35.6 


56 


63.0 


70.1 


18.4 


17.6 


35.7 


36.2 


57 


64.2 


71.3 


18.7 


17.9 


36.3 


36.9 



306 



ST. LUKE'S HOSPITAL REPORTS 



table iv (continued) 





Cuprous 


Cuprie 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


CeHj^O,, 


CoH^Os 


CjjE^Oh.HsO 


C^Hj^Oh.HjO 


58 


65.3 


72.6 


19.1 


18.3 


36.9 


37.5 


59 


66.4 


73.9 


19.4 


18.6 


37.6 


38.1 


60 


67.6 


75.1 


19.7 


18.9 


38.2 


38.8 


61 


68.7 


76.4 


20.0 


19.2 


38.8 


39.4 


62 


69.8 


77.6 


20.4 


19.5 


39.4 


40.0 


63 


70.9 


78.9 


20.7 


19.8 


40.1 


40.7 


64 


72.1 


80.1 


21.0 


20.1 


40.7 


41.3 


65 


73.2 


81.4 


21.4 


20.5 


41.3 


41.9 


66 


74.3 


82.6 


21.7 


20.8 


41.9 


42.5 


67 


75.4 


83.9 


22.0 


21.1 


42.6 


43.2 


68 


76.6 


85.1 


22.4 


21.4 


43.2 


43.8 


69 


77.7 


86.4 


22.7 


21.7 


43.8 


44.4 


70 


78.8 


87.6 


23.0 


22.0 


44.4 


45.1 


71 


79.9 


88.9 


23.4 


22.3 


45.1 


45.7 


72 


81.1 


90.1 


23.7 


22.7 


45.7 


46.3 


73 


82.2 


91.4 


24.0 


23.0 


46.3 


47.0 


74 


83.3 


92.6 


24.4 


23.3 


46.9 


47.6 


75 


84.4 


93.9 


24.7 


23.6 


47.5 


48.2 


76 


85.6 


95.1 


25.0 


23.9 


48.1 


48.9 


77 


86.7 


96.4 


25.4 


24.2 


48.8 


49.5 


78 


87.8 


97.6 


25.7 


24.5 


49.4 


50.1 


79 


88.9 


98.9 


26.0 


24.9 


50.0 


50.8 


80 


90.1 


100.1 


26.4 


25.2 


50.7 


51.4 


81 


91.2 


101.4 


26.7 


25.5 


51.3 


52.0 


82 


92.3 


102.6 


27.1 


25.8 


51.9 


52.7 


83 


93.4 


103.9 


27.4 


26.1 


52.6 


53.3 


84 


94.6 


105.1 


27.7 


26.4 


53.2 


53.9 


85 


95.7 


106.4 


28.1 


26.8 


53.9 


54.6 


86 


96.8 


107.6 


28.4 


27.1 


54.5 


55.2 


87 


97.9 


108.9 


28.7 


27.4 


55.1 


55.8 


88 


99.1 


110.1 


29.1 


27.7 


55.8 


56.5 


89 


100.2 


111.4 


29.4 


28.0 


56.4 


57.1 


90 


101.3 


112.7 


29.7 


28.3 


57.1 


57.7 


91 


102.4 


113.9 


30.1 


28.7 


57.7 


58.3 


92 


103.6 


115.2 


30.4 


29.0 


58.4 


58.9 


93 


104.7 


116.4 


30.8 


29.3 


59.0 


59.6 


94 


105.8 


117.7 


31.1 


29.6 


59.7 


60.2 


95 


106.9 


118.9 


31.4 


29.9 


60.3 


60.9 


96 


108.1 


120.2 


31.8 


30.2 


60.9 


61.5 


97 


109.2 


121.4 


32.1 


30.6 


61.6 


62.2 


98 


110.3 


122.7 


32.4 


30.9 


62.2 


62.8 


99 


111.5 


123.9 


32.8 


31.2 


62.8 


63.4 



DETERMINATION OF REDUCING SUGARS 



307 



table iv (continued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 6 H 12 0« 


C 6 H 12 6 


C i: H 22 O u . H 2 


C 12 H 22 O u .H 2 


100 


112.6 


125.2 


33.1 


31.5 


63.5 


64.1 


101 


113.7 


126.4 


33.5 


31.8 


64.2 


64.7 


102 


114.8 


127.7 


33.8 


32.2 


64.8 


65.3 


103 


116.0 


128.9 


34.1 


32.5 


65.4 


66.0 


104 


117.1 


130.2 


34.5 


32.8 


66.1 


66.6 


105 


118.2 


131.5 


34.8 


33.1 


66.8 


67.2 


106 


119.3 


132.7 


35.2 


33.4 


67.4 


67.8 


107 


120.5 


134.0 


35.5 


33.8 


68.0 


68.5 


108 


121.6 


135.2 


35.9 


34.1 


68.7 


69.1 


109 


122.7 


136.5 


36.2 


34.4 


69.3 


69.8 


110 


123.8 


137.7 


36.6 


34.7 


70.0 


70.4 


111 


125.0 


139.0 


36.9 


35.0 


70.6 


71.1 


112 


126.1 


140.2 


37.2 


35.4 


71.3 


71.7 


113 


127.2 


141.5 


37.5 


35.7 


71.9 


72.3 


114 


128.3 


142.7 


37.9 


36.0 


72.6 


73.0 


115 


129.4 


144.0 


38.2 


36.3 


73.2 


73.6 


116 


130.6 


145.2 


38.5 


36.7 


73.8 


74.2 


117 


131.7 


146.5 


38.9 


37.0 


74.5 


74.9 


118 


132.8 


147.7 


39.2 


37.3 


75.1 


75.5 


119 


134.0 


149.0 


39.6 


37.6 


75.8 


76.2 


120 


135.1 


150.2 


39.9 


37.9 


76.4 


76.8 


121 


136.2 


151.5 


40.3 


38.3 


77.1 


77.4 


122 


137.4 


152.7 


40.6 


38.6 


77.7 


78.1 


123 


138.5 


154.0 


40.9 


38.9 


78.4 


78.7 


124 


139.6 


155.2 


41.3 


39.2 


79.0 


79.4 


125 


140.7 


156.5 


41.6 


39.5 


79.7 


80.0 


126 


141.9 


157.7 


42.0 


39.9 


80.3 


80.6 


127 


143.0 


159.0 


42.3 


40.2 


81.0 


81.3 


128 


144.1 


160.2 


42.6 


40.5 


81.6 


81.9 


129 


145.2 


161.5 


43.0 


40.8 


82.3 


82.5 


130 


146.4 


162.7 


43.3 


41.2 


82.9 


83.2 


131 


147.5 


164.0 


43.7 


41.5 


83.6 


83.8 


132 


148.6 


165.2 


44.0 


41.8 


84.2 


84.5 


133 


149.7 


166.5 


44.4 


42.1 


84.9 


85.2 


134 


150.9 


167.7 


44.7 


42.5 


85.5 


85.8 


135 


152.0 


169.0 


45.1 


42.8 


86.2 


86.5 


136 


153.1 


170.2 


45.4 


43.1 


86.8 


87.1 


137 


154.2 


171.5 


45.7 


43.4 


87.4 


87.7 


138 


155.4 


172.7 


46.1 


43.8 


88.1 


88.3 


139 


156.5 


174.0 


46.4 


44.1 


88.7 


88.9 


140 


157.6 


175.2 


46.8 


44.4 


89.4 


89.6 


141 


158.7 


176.5 


47.1 


44.7 


90.0 


90.2 



308 ST. LUKE'S HOSPITAL REPORTS 

table iv (continued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 6 H 12 O 


C„H 12 6 


C^H^On.HoO 


C 12 H, 2 O n .H 2 < 


142 


159.9 


177.7 


47.5 


45.1 


90.7 


90.8 


143 


161.0 


179.0 


47.8 


45.4 


91.3 


91.5 


144 


162.1 


180.2 


48.1 


45.7 


92.0 


92.1 


145 


163.2 


181.5 


48.5 


46.0 


92.6 


92.8 


146 


164.4 


182.7 


48.8 


46.4 


93.3 


93.4 


147 


165.5 


184.0 


49.2 


46.7 


93.9 


94.0 


148 


166.6 


185.2 


49.5 


47.0 


94.6 


94.7 


149 


167.7 


186.5 


49.9 


47.4 


95.3 


95.3 


150 


168.9 


187.8 


50.2 


47.7 


95.9 


96.0 


151 


170.0 


189.0 


50.6 


48.0 


96.6 


96.6 


152 


171.1 


190.3 


50.9 


48.3 


97.2 


97.2 


153 


172.3 


191.5 


51.3 


48.7 


97.9 


97.9 


154 


173.4 


192.8 


51.6 


49.0 


98.5 


98.5 


155 


174.5 


194.0 


52.0 


49.3 


99.2 


99.2 


156 


175.6 


195.3 


52.3 


49.6 


99.8 


99.8 


157 


176.8 


196.5 


52.7 


50.0 


100.5 


100.4 


158 


177.9 


197.8 


53.0 


50.3 


101.1 


101.1 


159 


179.0 


199.0 


53.4 


50.6 


101.8 


101.7 


160 


180.1 


200.3 


53.7 


50.9 


102.4 


102.4 


161 


181.3 


201.5 


54.0 


51.3 


103.1 


103.0 


162 


182.4 


202.8 


54.4 


51.6 


103.7 


103.6 


163 


183.5 


204.0 


54.7 


51.9 


104.4 


104.3 


164 


184.6 


205.3 


55.1 


52.3 


105.0 


104.9 


165 


185.8 


206.5 


55.4 


52.6 


105.7 


105.6 


166 


186.9 


207.8 


55.8 


52.9 


106.3 


106.2 


167 


188.0 


209.0 


56.1 


53.3 


107.0 


106.8 


168 


189.1 


210.3 


56.5 


53.6 


107.6 


107.5 


169 


190.3 


211.5 


56.8 


53.9 


108.3 


108.1 


170 


191.4 


212.8 


57.2 


54.2 


108.9 


108.8 


171 


192.5 


214.0 


57.5 


54.6 


109.6 


109.4 


172 


193.6 


215.3 


57.9 


54.9 


110.2 


110.1 


173 


194.8 


216.5 


58.2 


55.2 


110.9 


110.7 


174 


195.9 


217.8 


58.6 


55.6 


111.6 


111.3 


175 


197.0 


219.0 


58.9 


55.9 


112.2 


112.0 


176 


198.1 


220.3 


59.3 


56.2 


112.9 


112.6 


177 


199.3 


221.5 


59.6 


56.6 


113.5 


113.3 


178 


200.4 


222.8 


60.0 


56.9 


114.2 


113.9 


179 


201.5 


224.0 


60.3 


57.2 


114.9 


114.5 


180 


202.6 


225.3 


60.7 


57.6 


115.5 


115.2 


181 


203.8 


226.5 


61.0 


57.9 


116.1 


115.8 


182 


204.9 


227.8 


61.4 


58.2 


116.8 


116.5 


183 


206.0 


229.0 


61.7 


58.6 


117.4 


117.1 



DETERMINATION OF REDUCING SUGARS 



309 



table iv (continued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 8 H 12 6 


C 8 H 12 3 


Ci^E^On-I^O 


C 12 H 22 O u . H 2 


184 


207.1 


230.3 


62.1 


58.9 


118.1 


117.8 


185 


208.3 


231.5 


62.4 


59.2 


118.8 


118.4 


186 


209.4 


232.7 


62.8 


59.6 


119.4 


119.0 


187 


210.5 


234.0 


63.1 


59.9 


120.1 


119.7 


188 


211.7 


235.3 


63.5 


60.2 


120.7 


120.3 


189 


212.8 


236.5 


63.9 


60.6 


121.4 


121.0 


190 


213.9 


237.8 


64.2 


60.9 


122.0 


121.6 


191 


215.0 


239.0 


64.6 


61.2 


122.7 


122.3 


192 


216.2 


240.3 


64.9 


61.6 


123.3 


122.9 


193 


217.3 


241.5 


65.3 


61.9 


124.0 


123.6 


194 


218.4 


242.8 


65.6 


62.2 


124.7 


124.2 


195 


219.5 


244.0 


66.0 


62.6 


125.3 


124.8 


196 


220.7 


245.3 


66.3 


62.9 


126.0 


125.5 


197 


221.8 


246.5 


66.7 


63.2 


126.6 


126.1 


198 


222.9 


247.8 


67.0 


63.6 


127.3 


126.8 


199 


224.0 


249.0 


67.4 


63.9 


127.9 


127.4 


200 


225.2 


250.3 


67.8 


64.2 


128.6 


128.1 


201 


226.3 


251.5 


68.1 


64.6 


129.2 


128.7 


202 


227.4 


252.8 


68.5 


64.9 


129.9 


129.4 


203 


228.5 


254.0 


68.8 


65.2 


130.6 


130.0 


204 


229.7 


255.3 


69.2 


65.6 


131.2 


130.6 


205 


230.8 


256.5 


69.5 


65.9 


131.9 


131.3 


206 


231.9 


257.8 


69.9 


66.2 


132.5 


131.9 


207 


233.0 


259.0 


70.2 


66.6 


133.2 


132.6 


208 


234.2 


260.3 


70.6 


66.9 


133.8 


133.2 


209 


235.3 


261.5 


71.0 


67.3 


134.5 


133.9 


210 


236.4 


262.8 


71.3 


67.6 


135.2 


134.5 


211 


237.6 


264.0 


71.7 


67.9 


135.8 


135.2 


212 


238.7 


265.3 


72.0 


68.3 


136.5 


135.8 


213 


239.8 


266.5 


72.4 


68.6 


137.1 


136.5 


214 


240.9 


267.8 


72.7 


69.0 


137.8 


137.1 


215 


242.1 


269.0 


73.1 


69.3 


138.5 


137.8 


216 


243.2 


270.3 


73.4 


69.6 


139.1 


138.4 


217 


244.3 


271.5 


73.8 


70.0 


139.8 


139.1 


218 


245.4 


272.8 


74.2 


70.3 


140.4 


139.7 


219 


246.6 


274.1 


74.5 


70.7 


141.1 


140.3 


220 


247.7 


275.4 


74.9 


71.0 


141.8 


141.0 


221 


248.7 


276.6 


75.2 


71.4 


142.4 


141.6 


222 


249.9 


277.9 


75.6 


71.7 


143.1 


142.3 


223 


251.0 


279.1 


76.0 


72.0 


143.7 


142.9 


224 


252.1 


280.4 


76.3 


72.4 


144.4 


143.6 


225 


253.3 


281.6 


76.7 


72.7 


145.1 


144.2 



310 



ST. LUKE'S HOSPITAL REPORTS 



table iv (contmued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 6 H 12 6 


C H 12 O 6 


CuHjjOu.HjO 


C^H^Ou.HgO 


226 


254.4 


282.9 


77.0 


73.1 


145.7 


144.9 


227 


255.6 


284.1 


77.4 


73.4 


146.4 


145.5 


228 


256.7 


285.4 


77.8 


73.7 


147.0 


146.2 


229 


257.8 


286.6 


78.1 


74.1 


147.7 


146.8 


230 


258.9 


287.9 


78.5 


74.4 


148.4 


147.5 


231 


260.1 


289.1 


78.8 


74.8 


149.0 


148.1 


232 


261.2 


290.4 


79.2 


75.1 


149.7 


148.8 


233 


262.3 


291.6 


79.6 


75.4 


150.3 


149.4 


234 


263.4 


292.9 


79.9 


75.8 


151.0 


150.1 


235 


264.6 


294.1 


80.3 


76.1 


151.7 


150.7 


236 


265.7 


295.4 


80.6 


76.5 


152.3 


151.4 


237 


266.8 


296.6 


81.0 


76.8 


153.0 


152.0 


238 


268.0 


297.9 


81.4 


77.2 


153.6 


152.6 


239 


269.1 


299.1 


81.7 


77.5 


154.3 


153.3 


240 


270.2 


300.4 


82.1 


77.8 


155.0 


153.9 


241 


271.3 


301.6 


82.5 


78.2 


155.6 


154.6 


242 


272.5 


302.9 


82.8 


78.5 


156.3 


155.2 


243 


273.6 


304.1 


83.2 


78.9 


157.0 


155.9 


244 


274.7 


305.4 


83.5 


79.2 


157.6 


156.5 


245 


275.8 


306.6 


83.9 


79.6 


158.3 


157.2 


246 


277.0 


307.9 


84.3 


79.9 


159.0 


157.8 


247 


278.1 


309.1 


84.6 


80.2 


159.6 


158.5 


248 


279.2 


310.4 


85.0 


80.6 


160.3 


159.1 


249 


280.3 


311.6 


85.4 


80.9 


160.9 


159.8 


250 


281.5 


312.9 


85.7 


81.3 


161.6 


160.4 


251 


282.6 


314.1 


86.1 


81.6 


162.2 


161.1 


252 


283.7 


315.4 


86.5 


82.0 


162.9 


161.7 


253 


284.8 


316.6 


86.8 


82.3 


163.6 


162.4 


254 


286.0 


317.9 


87.2 


82.7 


164.2 


163.0 


255 


287.1 


319.1 


87.6 


83.0 


164.9 


163.7 


256 


288.2 


320.4 


87.9 


83.4 


165.6 


164.3 


257 


289.3 


321.6 


88.3 


83.7 


166.2 


165.0 


258 


290.5 


322.9 


88.7 


84.1 


166.9 


165.6 


259 


291.6 


324.1 


89.0 


84.4 


167.6 


166.3 


260 


292.7 


325.4 


89.4 


84.8 


168.2 


166.9 


261 


293.8 


326.6 


89.8 


85.1 


168.9 


167.6 


262 


295.0 


327.9 


90.1 


85.5 


169.5 


168.3 


263 


296.1 


329.1 


90.5 


85.8 


170.2 


168.9 


264 


297.2 


330.4 


90.8 


86.1 


170.9 


169.6 


265 


298.3 


331.6 


91.2 


86.5 


171.6 


170.2 


266 


299.5 


332.9 


91.6 


86.8 


172.2 


170.9 


267 


300.6 


334.1 


91.9 


87.2 


172.9 


171.5 



DETERMINATION OF REDUCING SUGARS 



311 



table iv (continued) 





Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 6 H 12 O b 


CaHjjOg 


C12H22OU.H2O 


Ci2H 22 O u .H 2 


268 


301.7 


335.4 


92.3 


87.5 


173.5 


172.2 


269 


302.8 


336.7 


92.7 


87.9 


174.2 


172.8 


270 


304.0 


338.0 


93.1 


88.2 


174.9 


173.5 


271 


305.1 


339.2 


93.4 


88.6 


175.5 


174.1 


272 


306.2 


340.5 


93.8 


88.9 


176.2 


174.8 


273 


307.3 


341.7 


94.2 


89.3 


176.9 


175.4 


274 


308.5 


343.0 


94.5 


89.6 


177.5 


176.1 


275 


309.6 


344.2 


94.9 


90.0 


178.2 


176.7 


276 


310.7 


345.5 


95.3 


90.3 


178.9 


177.4 


277 


311.9 


346.7 


95.6 


90.7 


179.5 


178.0 


278 


313.0 


348.0 


96.0 


91.1 


180.2 


178.7 


279 


314.1 


349.2 


96.4 


91.4 


180.9 


179.3 


280 


315.2 


350.5 


96.7 


91.8 


181.5 


180.0 


281 


316.4 


351.7 


97.1 


92.1 


182.2 


180.6 


282 


317.5 


353.0 


97.5 


92.5 


182.9 


181.3 


283 


318.6 


354.2 


97.9 


92.8 


183.5 


181.9 


284 


319.7 


355.5 


98.2 


93.1 


184.2 


182.6 


285 


320.9 


356.7 


98.6 


93.5 


184.9 


183.2 


286 


322.0 


358.0 


99.0 


93.9 


185.5 


183.9 


287 


323.1 


359.2 


99.4 


94.2 


186.2 


184.6 


288 


324.2 


360.5 


99.7 


94.6 


186.9 


185.2 


289 


325.3 


361.7 


100.1 


94.9 


187.6 


185.9 


290 


326.4 


363.0 


100.5 


95.3 


188.2 


186.5 


291 


327.5 


364.2 


100.8 


95.6 


188.8 


187.2 


292 


328.7 


365.5 


101.2 


96.0 


189.5 


187.8 


293 


329.9 


366.7 


101.6 


96.3 


190.1 


188.5 


294 


331.0 


368.0 


101.9 


96.7 


190.8 


189.1 


295 


332.1 


369.2 


102.3 


97.1 


191.4 


189.8 


296 


333.3 


370.5 


102.7 


97.4 


192.1 


190.4 


297 


334.4 


371.7 


103.1 


97.8 


192.8 


191.1 


298 


335.5 


373.0 


103.4 


98.1 


193.5 


191.8 


299 


336.6 


374.2 


103.8 


98.5 


194.2 


192.4 


300 


337.8 


375.5 


104.2 


98.9 


194.9 


193.1 


301 


338.9 


376.7 


104.6 


99.2 


195.6 


193.7 


302 


340.0 


378.0 


105.0 


99.6 


196.2 


194.4 


303 


341.1 


379.2 


105.3 


99.9 


196.9 


195.0 


304 


342.3 


380.5 


105.7 


100.3 


197.6 


195.7 


305 


343.4 


381.7 


106.1 


100.6 


198.3 


196.3 


306 


344.5 


383.0 


106.4 


101.0 


198.9 


197.0 


307 


345.6 


384.2 


106.8 


101.3 


199.6 


197.6 


308 


346.8 


385.5 


107.2 


101.7 


200.3 


198.3 


309 


347.9 


386.7 


107.6 


102.1 


200.9 


199.0 



312 



ST. LUKE'S HOSPITAL REPORTS 



table rv (continued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


CeH^Oe 


C 6 H i; O e 


GuHjjjOh.HjO 


C 12 H, 2 11 .H i! < 


310 


349.0 


388.0 


107.9 


102.4 


201.6 


199.6 


311 


350.1 


389.2 


108.3 


102.8 


202.3 


200.3 


312 


351.3 


390.5 


108.7 


103.1 


202.9 


200.9 


313 


352.4 


391.7 


109.1 


103.5 


203.6 


201.6 


314 


353.5 


393.0 


109.5 


103.8 


204.3 


202.2 


315 


354.6 


394.2 


109.8 


104.2 


204.9 


202.9 


316 


355.8 


395.5 


110.2 


104.6 


205.5 


203.6 


317 


356.9 


396.7 


110.6 


104.9 


206.2 


204.2 


318 


358.0 


398.0 


111.0 


105.3 


206.8 


204.9 


319 


359.1 


399.2 


111.4 


105.6 


207.5 


205.5 


320 


360.3 


400.5 


111.7 


106.0 


208.2 


206.2 


321 


361.4 


401.7 


112.1 


106.4 


208.9 


206.8 


322 


362.5 


403.0 


112.5 


106.7 


209.6 


207.5 


323 


363.7 


404.2 


112.9 


107.1 


210.3 


208.2 


324 


364.8 


405.5 


113.2 


107.5 


211.0 


208.8 


325 


365.9 


406.7 


113.6 


107.8 


211.7 


209.5 


326 


367.0 


408.0 


114.0 


108.2 


212.3 


210.1 


327 


368.2 


409.2 


114.4 


108.5 


213.0 


210.8 


328 


369.3 


410.5 


114.8 


108.9 


213.6 


211.5 


329 


370.4 


411.8 


115.1 


109.3 


214.3 


212.1 


330 


371.5 


413.1 


115.5 


109.6 


214.9 


212.8 


331 


372.7 


414.3 


115.9 


110.0 


215.6 


213.4 


332 


373.8 


415.6 


116.3 


110.3 


216.3 


214.1 


333 


374.9 


416.8 


116.7 


110.7 


217.0 


214.7 


334 


376.0 


418.1 


117.0 


111.1 


217.7 


215.4 


335 


377.2 


419.3 


117.4 


111.5 


218.4 


216.1 


336 


378.3 


420.6 


117.8 


111.8 


219.1 


216.7 


337 


379.4 


421.9 


118.2 


112.2 


219.8 


217.4 


338 


380.5 


423.1 


118.6 


112.5 


220.4 


218.0 


339 


381.7 


424.4 


119.0 


112.9 


221.1 


218.7 


340 


382.8 


425.6 


119.4 


113.3 


221.7 


219.3 


341 


383.9 


426.9 


119.8 


113.6 


222.4 


220.0 


342 


385.0 


428.1 


120.1 


114.0 


223.0 


220.7 


343 


386.2 


429.4 


120.5 


114.4 


223.7 


221.3 


344 


387.3 


430.6 


120.9 


114.7 


224.4 


222.0 


345 


388.4 


431.9 


121.3 


115.1 


225.1 


222.6 


346 


389.6 


433.1 


121.7 


115.5 


225.8 


223.3 


347 


390.7 


434.4 


122.1 


115.8 


226.5 


224.0 


348 


391.8 


435.6 


122.4 


116.2 


227.2 


224.6 


349 


392.9 


436.9 


122.8 


116.6 


227.9 


225.3 


350 


394.0 


438.1 


123.2 


117.0 


228.5 


225.9 


351 


395.2 


439.4 


123.6 


117.3 


229.2 


226.6 



DETERMINATION OF REDUCING SUGARS 



313 



table iv (continued) 





Cuprous 


Cupric 


Glucose 


sugar 


Lactos 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


CeHuOg 


c^o. 


CuHjjOu.I 


352 


396.3 


440.6 


124.0 


117.7 


229.9 


353 


397.4 


441.9 


124.3 


118.1 


230.6 


354 


398.6 


443.1 


124.7 


118.4 


231.2 


355 


399.7 


444.4 


125.1 


118.8 


231.9 


356 


400.8 


445.7 


125.5 


119.2 


232.6 


357 


401.9 


446.9 


125.9 


119.5 


233.2 


358 


403.1 


448.1 


126.3 


119.9 


233.9 


359 


404.2 


449.4 


126.7 


120.3 


234.6 


360 


405.3 


450.6 


127.1 


120.7 


235.3 


361 


406.4 


451.9 


127.5 


121.0 


236.0 


362 


407.6 


453.1 


127.9 


121.4 


236.6 


363 


408.7 


454.4 


128.2 


121.8 


237.3 


364 


409.8 


455.6 


128.6 


122.1 


238.0 


365 


410.9 


456.9 


129.0 


122.5 


238.7 


366 


412.1 


458.1 


129.4 


122.9 


239.4 


367 


413.2 


459.4 


129.8 


123.2 


240.1 


368 


414.3 


460.6 


130.2 


123.6 


240.7 


369 


415.4 


461.9 


130.6 


124.0 


241.4 


370 


416.6 


463.1 


131.0 


124.3 


242.1 


371 


417.7 


464.4 


131.4 


124.7 


242.8 


372 


418.8 


465.6 


131.8 


125.1 


243.5 


373 


420.0 


466.9 


132.1 


125.5 


244.1 


374 


421.1 


468.1 


132.5 


125.8 


244.8 


375 


422.2 


469.4 


132.9 


126.2 


245.5 


376 


423.3 


470.6 


133.3 


126.6 


246.2 


377 


424.5 


471.9 


133.7 


127.0 


246.8 


378 


425.6 


473.0 


134.1 


127.4 


247.5 


379 


426.7 


474.3 


134.5 


127.7 


248.2 


380 


427.8 


475.6 


134.9 


128.1 


248.9 


381 


429.0 


476.8 


135.3 


128.5 


249.6 


382 


430.1 


478.1 


135.7 


128.8 


250.2 


383 


431.2 


479.3 


136.1 


129.2 


250.9 


384 


432.3 


480.6 


136.5 


129.6 


251.6 


385 


433.5 


481.8 


136.9 


130.0 


252.3 


386 


434.6 


483.1 


137.3 


130.3 


253.0 


387 


435.7 


484.3 


137.7 


130.7 


253.6 


388 


436.8 


485.6 


138.0 


131.1 


254.3 


389 


438.0 


486.9 


138.4 


131.5 


255.0 


390 


439.1 


488.2 


138.8 


131.9 


255.7 


391 


440.2 


489.4 


139.2 


132.2 


256.4 


392 


441.3 


490.7 


139.6 


132.6 


257.0 


393 


442.4 


491.9 


140.0 


133.0 


257.7 



Invert 

Maltose 
Mg. 



227.3 
227.9 
228.6 
229.2 
229.9 
230.6 
231.2 
231.9 
232.6 
233.2 
233.9 
234.5 
235.2 
235.9 
236.5 
237.2 
237.8 
238.5 
239.2 
239.8 
240.5 
241.2 
241.8 
242.5 
243.1 
243.8 
244.5 
245.1 
245.8 
246.5 
247.1 
247.8 
248.5 
249.1 
249.8 
250.4 
251.1 
251.8 
252.4 
253.1 
253.8 
254.4 



314 



ST. LUKE'S HOSPITAL REPORTS 



table rv (continued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C 6 H 12 8 


CoH^Og 


CjsH^Ou. H 2 


C^HjjOu.HjO 


394 


443.6 


493.2 


140.4 


133.4 


258.4 


255.1 


395 


444.7 


494.4 


140.8 


133.8 


259.1 


255.8 


396 


445.9 


495.7 


141.2 


134.2 


259.8 


256.4 


397 


447.0 


496.9 


141.6 


134.5 


260.5 


257.1 


398 


448.1 


498.2 


142.0 


134.9 


261.1 


257.8 


399 


449.2 


499.5 


142.4 


135.3 


261.8 


258.4 


400 


450.3 


500.7 


142.8 


135.7 


262.5 


259.1 


401 


451.5 


502.0 


143.2 


136.1 


263.2 


259.8 


402 


452.6 


503.2 


143.6 


136.4 


263.9 


260.4 


403 


453.7 


504.5 


144.0 


136.8 


264.5 


261.1 


404 


454.8 


505.7 


144.4 


137.2 


265.2 


261.8 


405 


456.0 


507.0 


144.8 


137.6 


265.9 


262.4 


406 


457.1 


508.2 


145.2 


137.9 


266.6 


263.1 


407 


458.2 


509.5 


145.6 


138.3 


267.3 


263.8 


408 


459.4 


510.7 


146.0 


138.7 


267.9 


264.4 


409 


460.5 


512.0 


146.4 


139.1 


268.6 


265.1 


410 


461.6 


513.2 


146.8 


139.5 


269.3 


265.8 


411 


462.7 


514.5 


147.2 


139.9 


270.0 


266.4 


412 


463.8 


515.7 


147.6 


140.2 


270.7 


267.1 


413 


465.0 


517.0 


148.0 


140.6 


271.4 


267.8 


414 


466.1 


518.2 


148.4 


141.0 


272.1 


268.4 


415 


467.2 


519.5 


148.8 


141.4 


272.8 


269.1 


416 


468.4 


520.7 


149.2 


141.8 


273.5 


269.7 


417 


469.5 


522.0 


149.6 


142.2 


274.1 


270.4 


418 


470.6 


523.2 


150.0 


142.6 


274.8 


271.1 


419 


471.8 


524.5 


150.4 


143.0 


275.5 


271.8 


420 


472.9 


525.7 


150.8 


143.3 


276.2 


272.4 


421 


474.0 


527.0 


151.2 


143.7 


276.9 


273.1 


422 


475.1 


528.2 


151.6 


144.1 


277.6 


273.8 


423 


476.2 


529.5 


152.0 


144.5 


278.3 


274.4 


424 


477.4 


530.7 


152.4 


144.9 


278.9 


275.1 


425 


478.5 


532.0 


152.8 


145.3 


279.6 


275.8 


426 


479.6 


533.2 


153.2 


145.7 


280.3 


276.5 


427 


480.7 


534.5 


153.6 


146.1 


280.9 


277.1 


428 


481.9 


535.7 


154.0 


146.4 


281.6 


277.8 


429 


483.0 


537.0 


154.4 


146.8 


282.3 


278.5 


430 


484.1 


538.2 


154.8 


147.2 


282.9 


279.1 


431 


485.3 


539.5 


155.3 


147.6 


283.6 


279.8 


432 


486.4 


540.7 


155.7 


148.0 


284.3 


280.5 


433 


487.5 


542.0 


156.1 


148.4 


285.0 


281.1 


434 


488.6 


543.2 


156.5 


148.8 


285.7 


281.8 


435 


489.7 


544.5 


156.9 


149.1 


286.4 


282.5 



DETERMINATION OF REDUCING SUGARS 



315 



table rv (contmued) 











Invert 








Cuprous 


Cupric 


Glucose 


sugar 


Lactose 


Maltose 


Copper 


oxide 


oxide 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


Mg. 


C.H^O, 


C 6 H 12 8 


OuHgjOu-HjO 


C 12 H 22 O u .H 2 


436 


490.9 


545.7 


157.3 


149.5 


287.1 


283.1 


437 


492.0 


547.0 


157.7 


149.9 


287.8 


283.S 


438 


493.1 


548.2 


158.1 


150.3 


288.5 


284.5 


439 


494.3 


549.5 


158.5 


150.7 


289.2 


285.2 


440 


495.4 


550.7 


158.9 


151.1 


289.9 


285.8 


441 


496.5 


552.0 


159.3 


151.5 


290.6 


286.5 


442 


497.6 


553.2 


159.8 


151.9 


291.3 


287.2 


443 


498.8 


554.5 


160.2 


152.3 


292.0 


287.8 


444 


499.9 


555.7 


160.6 


152.7 


292.7 


288.5 


445 


501.0 


557.0 


161.0 


153.1 


293.4 


289.2 


446 


502.1 


558.2 


161.4 


153.5 


294.1 


289.8 


447 


503.2 


559.5 


161.8 


153.9 


294.8 


290.5 


448 


504.4 


560.7 


162.2 


154.3 


295.5 


291.2 


449 


505.5 


562.0 


162.6 


154.7 


296.2 


291.9 


450 


506.6 


563.3 


163.0 


155.1 


296.9 


292.5 



ATROPIN THERAPY IN DIABETES MELLITUS.*t 
Herman 0. Mosenthal, M.D. 

The atropin therapy of diabetes mellitus has recently been ad- 
vocated by Rudisch 1 and by Forchheimer. 2 Carbohydrate tolerance 
is, according to Rudisch, greater with atropin than without. The 
more striking results were obtained with atropin sulphate, though in 
some instances atropin methyl bromid was substituted. 

The following two cases of diabetes mellitus were tested out with 
atropin sulphate. A constant weighed diet, as detailed in the pro- 
tocols, was given. When the daily variations in the amount of glu- 
cose excreted had been reduced to a minimum, atropin sulphate was 
administered in increasing doses for a sufficiently long period of time 
to give the drug a chance to exert any action of which it was capable. 
With both subjects the experiments were continued until toxic effects 
were observed. Under these conditions the glycosuria should be di- 
minished if atropin sulphate is capable of increasing the carbohydrate 
tolerance. 

Any drug which modifies the carbohydrate metabolism may in- 
fluence the formation of the so-called acid bodies, acetone, diacetic 
acid and beta-oxybutyric acid. If atropin diminished the utilization 
of glucose within the organism, the acid bodies would increase in the 
urine. Therefore there is some interest attached to the determination 
of these substances in a study of this kind. In one of the cases ob- 
served, small but persistent amounts of acetone and diacetic acid 
were present in the urine, as shown by previous qualitative tests. 
Any possible increase in these substances was measured by the am- 
monia output and its relation to the total nitrogen of the urine. 
Normally the amount of ammonia nitrogen excreted is about 5 per 

♦From the service of Dr. F. C. Wood, St Luke's Hospital, New York. 
tReprinted from the Journal of the American Medical Association, March 
16, 1912. 

'Rudisch, J. : The Journal A. M. A, Oct. 23, 1909, p. 1366. 
'Forchheimer, F. : Am. Jour. Med. Sc, 1911, cxli, 157. 

316 



ATROPIN THERAPY IN DIABETES 



317 



cent of the total nitrogen. A rise in this percentage indicates an in- 
crease in the excretion of acid substances. 

In these analyses the glucose was determined by Benedict's meth- 
od, 3 the ammonia according to Folin, and the nitrogen by the Kjel- 
dahl process. The presence or absence of acetone was established 
by the Legal reaction, that of diacetic acid by the ferric chlorid test. 



TABLE 1— URINE ANALYSES AND MEDICATION IN A CASE OF DIABETES 

MELLITUS (CASE 1). 

Urine in Twenty-four Hours. 



rH 

OS 
rH 


V 

e 


u 

o> 

oT • 

o o 


a 

M 

<u 

00 

O 


2a 

— a 


a 

bo 

eS 

d 
o 


■4-» . 

a * o 


3 a 

a a 


>> 

a 

Q 

O) 

O. 




<D 


3 


V v 


o 


ol a> 


a 


a hvi 


®rh 


<u 




"3 


o 


SO 


3 


3* 


a 


a-° 


uO 


o 




Q 


> 


5 


3 


H 


o 


< 


< 


Q 


Symptoms. 


3/18 


1,460 


2.2 


23.4 


9.1 


.34 


3.1* 









3/19 


1,290 


2.4 


30.3 


9.6 


.45 


3.9* 









3/20 


1,720 


2.8 


47.5 


8.9 


.55 


5.1 









3/21 


1,680 


1.9 


31.1 


9.9 


.58 


4.9 









3/22 


1,080 


2.1 


22.9 


7.7 


.48 


5.1 









3/23 


1,200 


2.0 


23.5 


9.7 


.58 


4.9 


1/100 


3 




3/24 


1,320 


2.0 


26.7 


9.8 


.55 


4.6 


1/100 


3 


Mouth slightly dry- 


3/25 


1,800 


1.5 


26.7 


9.9 


.63 


5.2 


1/100 


3 


Cheeks flushed. 


3/26 


1,910 


1.5 


29.0 


12.2 


.79 


5.4 


1/100 


4 




3/27 


1,560 


1.2 


18.4 


9.7 


.57 


4.9 


1/50 


3 




3/28 


1,300 


1.6 


20.2 


9.2 


.65 


5.8 


1/50 


3 




3/29 


1,480 


0.6 


8.7 


5.5 


.43 


6.5 


1/50 


3 




3/30 


1,300 


0.8 


13.4 


7.0 


.54 


6.3 


1/25 


3 


Vertigo ; very dim vision. 


3/31 


1,940 


1.6 


30.3 


10.1 


.81 


6.6 


1/25 


2 




4/1 


1,560 


1.3 


19.5 


10.1 


.66 


5.4 


1/25 


2 


Head "feels full." 


4/2 


1,730 


1.9 


32.0 


10.1 


.75 


6.1 









4/3 


1,200 


2.9 


35.4 


8.7 


.59 


5.6 









4/4 


930 


1.8 


17.1 


7.8 


.59 


6.2 









4/5 


1,175 


2.1 


24.9 


12.6 


.76 


5.0 










•The initial low figures for ammonia may be regarded as the after-effects of bicar- 
bonate of soda taken before admission to the hospital. 

'Benedict, S. R. : The Journal A. M. A, Oct. 7, 1911, p. 1193. 



318 



ST. LUKE'S HOSPITAL REPORTS 



TABLE 2. RECORD OP URINE ANALYSES AND MEDICATION IN A CASE OP 

DIABETES MELLITUS (CASE 2). 

Urine in Twenty-four Hours. 



1-1 

a> 

V 
+-> 
OS 

C 


w 

a 

3 
© 
> 


u 
m 

o & 
3 <o 

a r J 

3 


a 

Ml 

■ 
o 

3 

o 


CSO 
08 ft 

50 

0P 

fa 


Q 
u 
<o 

ft 

ce 
s> 

00 

o 
Q 




8/9 


1,000 


1.0 


9.6 







Symptoms. 


8/10 


740 


1.1 


7.8 









8/11 


1,150 


1.1 


12.2 









8/12 


860 


1.0 


8.6 









8/13 


810 


1.1 


8.8 









8/14 








1/100 


3 




8/15 


980 


0.6 


6.2 


1/100 


3 


Mouth slightly dry. 


8/16 








1/100 


3 




8/17 


1,085 


0.7 


7.2 


1/100 


3 




8/18 


1,145 


0.7 


8.1 


1/100 


3 


Vision dim temporar 


8/19 


1,095 


0.8 


9.1 


2/100 


3 




8/20 


1,550 


0.5 


8.2 


2/100 


3 




8/21 


1,485 


0.3 


4.6 


2/100 


3 


Mouth very dry. 


8/22 


1,340 


0.3 


4.0 


3/100 


3 




8/23 


1,150 


0.4 


4.1 


3/100 


3 




8/24 


1,690 


1.0 


16.6 


3/100 


3 




8/25 


1,155 


1.0 


11.6 


4/100 


3 




8/26 


1,800 


1.7 


29.9 


4/100 


3 




8/27 


1,030 


1.3 


12.9 


5/100 


3 


Face flushed. 


8/28 


2,360 


0.4 


9.9 


5/100 


3 




8/29 


1,920 


0.7 


13.6 


6/100 


3 




8/30 


1,720 


0.4 


7.1 


6/100 


3 




8/31 


1,600 


0.5 


7.2 


7/100 


3 


Mouth Intensely dry 


9/1 


865 


1.0 


8.3 


7/100 


3 


Pupils dilated. 


9/2 


1,430 


0.4 


6.0 


7/100 


3 




9/3 


1,300 


0.5 


5.9 









9/4 


1,400 


2.3 


31.8 









9/5 


1,045 


1.1 


11.1 









9/6 


1,400 


1.8 


25.2 










Case 1. — Patient, a tailor, of Russian birth, aged 38, about two years ago 
began to suffer with polyuria, thirst, increased appetite and loss of weight. 
Glucose was discovered in the urine, but dietary restrictions were never ob- 
served for very long periods of time. After being treated for one month at 
the Vanderbilt Clinic as an out-patient, he was sent to Dr. Wood's service at 
St. Luke's Hospital. The patient's urine gave constant positive reactions of 
moderate intensity for acetone and diacetic acid. He was placed on the 
following diet: 

Breakfast. — Coffee or tea, with V/ 2 ounces of cream ; two eggs, cooked with 
y 2 ounce butter; 3 ounces ham; one slice bread, weight exactly 1 ounce, with 
14 ounce butter. 

Lunch. — Bouillon, with one raw egg; 3 ounces any lean meat, 1 ounce 



ATROPIN THERAPY IN DIABETES 319 

bacon ; vegetables from list,* 3 ounces, with % ounce butter or oil ; 1 ounce 
whisky or brandy ; one slice bread, weight exactly 1 ounce, with *4 ounce butter. 

Afternoon tea, with % ounce cream. 

Dinner. — Any clear soup ; 4 ounces any lean meat ; vegetables from list,* 3 
ounces, with y 2 ounce butter or oil ; 1 ounce cheese, English, pineapple, Swiss, 
or full-cream cheese; one slice white bread, weight exactly 1 ounce, with % 
ounce butter ; 1 ounce whiskey or brandy ; demitasse coffee. 

Case 2. — Patient, a native of France, aged 59, foreman in a factory, was 
found to have sugar in his urine about four years ago. Only during the last 
year before examination had he been complaining of diabetic symptoms : occa- 
sional increased appetite and thirst. There had been some stiffness, pain and 
weakness in the legs. The neurologic department of the Vanderbilt Clinic 
diagnosed the case as one of multiple neuritis of diabetic origin. The urine 
occasionally showed a trace of acetone, but no diacetic acid. After being ob- 
served for one month at the Vanderbilt Clinic, he was sent to St. Luke's Hos- 
pital. He was given the same diet as the patient in Case 1, except that 2 
ounces of bread were ordered with each meal instead of 1. 

The above reports give no indication that atropin sulphate effects 
any change in the carbohydrate tolerance of sufficient importance to 
make the drug of clinical value in the treatment of diabetes mellitus. 

Vegetables allowed were: Asparagus, beet greens, Brussels sprouts, cab- 
bage, cauliflower, celery, chicory, cresses, cucumbers, egg plant, endive, lettuce, 
mushrooms, radishes, rhubarb, salsify, spinach, string beans, tomatoes, vege- 
table marrow. 



ANATOMICAL STUDY OF A THORACOPAGUS. 
J. R. Pawling, M.D. 
From the Pathological Department. 
F. C. Wood, M.D., Director. 

This specimen was sent to the laboratory from the service of Dr. 
C. L. Gibson, in February, 1911. Some one had named the twins 
"John and Mary," evidently forgetting his embryology, for they are, 
of course, identical or homologous twins; i.e., have developed in the 
same amniotic sac and have resulted probably from the division of a 
single ovum. In such cases, there may be produced two separate in- 
dividuals, i.e., normal twins of like sex; or, on the other hand, there 
may be formed, in some way, a double monster. 

We may classify double monsters in two main classes: first, those 
showing decidedly unequal development; for example, the case of a 
more or less completely developed autosite having an aeardiac para- 
site springing from its thorax ; and, second, those showing practically 
equal development. This second class may still further be divided 
(according to Adami) into two classes: first, those that have resulted 
from cleavage in the very early embryo — at the superior pole, at the 
inferior pole, at both, or between these poles ; i.e., if cells of the head 
center become split, those cells developing from them at each side 
would form duplicate sets of tissue, a double head, for instance; 
whereas the cells of the rump center developing in the normal way 
would produce a single body. (Examples of superior duplication 
would thus include all varieties, from a monster having two heads, 
four arms, a double trunk, and two legs, down to a case simply of 
bifurcation of the hypophysis of the brain.) His second class in- 
cludes those that he believes have resulted from fusion of what would 
otherwise have become identical twins; and these may be subdivided 
according to the location and extent of this fusion. 

The specimen we have to consider belongs to this latter class, and 
it may be termed an equal monosymmetrical thoracopagus. The term 
equal is used because the twins show practically the same measure- 

320 




Fig- 1- — The specimen before dissection, showing the double thumb. 



ANATOMICAL STUDY OF A THORACOPAGUS 321 

ments. They are monosymmetrical because, as is more often the case, 
the union is not exactly face to face ; i.e., the arms, for example, are 
somewhat farther apart on one side than on the other because the 
antero-posterior planes of the fetuses do not exactly coincide. The 
term thoracopagus is really not exact because the union includes not 
only the thorax but the upper part of the abdomen as well, for it will 
be noticed in the photograph taken before dissection that the cord 
springs from the under surface of the bond of union. (The same 
picture shows also the double thumb in one fetus which Nature added 
as a finishing touch to an already interesting specimen.) 

The age of the twins may be estimated at about four months, to 
judge from their development; the mother's last menstruation oc- 
curred October 14, 1910, and she aborted February 2, 1911. 

In order to show the relations of the viscera, one side of the speci- 
men (which, for convenience, we may speak of as the "front") was 
removed completely. In dissecting up the skin, the recti muscles 
were exposed and found to extend from the lower ribs downward 
and outward to each pubis. By making translucent the portion of 
chest-wall removed, we found that instead of the sternum of each 
side coming in contact face to face (as, at first glance, we might ex- 
pect), each sternum had split, the corresponding parts on each side, 
i.e., the front and back of the specimen, forming a separate sternum. 

The thorax, therefore, is common ; it contains a single pericardium 
inclosing one heart having five chambers. The apex of the heart, as 
we look at the specimen, points directly forward. The auricles lie 
at about the same level, so that the long axis of the heart is in a hori- 
zontal plane. Two aortae leave the two left ventricles, the arch in 
each fetus taking the normal direction. Two inferior venas cava? pierce 
the diaphragm and enter a common right auricle. This is continuous 
with a common left auricle. Into this common chamber enters also a 
pulmonary vein from the right fetus. (The other pulmonary veins 
have not been followed.) The course taken by the blood seems to 
have been as follows: entering the common right auricle by the in- 
ferior and superior venae cava?, it reached the common left auricle, 
and thence to the two left ventricles and the two aortae to the arterial 
system, but also partly back to the lungs through the ductus arterio- 
sus of each fetus. Some left the common right auricle to enter the 
single right ventricle, then through the pulmonary artery of the right 
fetus to the lungs on that side. The pulmonary artery of the left 
fetus appears to be represented only by a fibrous cord which extends 



322 ST. LUKE'S HOSPITAL REPORTS 

to the root of the aorta (there being no right ventricle for that fetus), 
so that its lungs received blood only from its aorta by way of the 
ductus arteriosus. 

The lungs show the usual divisions into lobes. The left lung of 
the right fetus presents a cardiac incisure which receives the apex 
of the heart. The left lung of the left fetus is abnormal in that a 
lobe hooks over the aorta, and there is, in addition, a groove accom- 
modating the left superior vena cava, which runs down between the 
outer surface of the left lung and the chest wall. 

We come next to the diaphragm, which is single and arches over 
a single large liver. The upper part of the liver has in the median 
line a shallow groove, from which a thin fibrous partition extended 
to the abdominal wall. The umbilical vein is single and enters the 
liver through a deep notch situated at about the center of this "front" 
surface. Above and below this the liver is continuous across. At 
each side of this opening there is a deep horizontal cut, as if to rep- 
resent what would have been an umbilical fissure in each liver. The 
umbilical vein, followed into the substance of the liver, divides into 
two branches: that at the left becomes lost by smaller subdivisions, 
but the right branch also connects by a distinct branch with the right 
inferior vena cava, this connection being a ductus venosus. 

The intestinal tract is very interesting. As the abdominal wall was 
opened, a small, pointed pouch, about half a centimeter long, was 
seen adherent to the inner surface of the cord. It is the remnant of 
the vitelline duet, or a Meckel's diverticulum. This opens into a 
horizontal loop of gut and is located at a Y-shaped junction formed 
by what we may call a common jejunum meeting the two ilea. That 
is to say, below this point each fetus has its own intestinal tract. 
The cecum and appendix are located at the left side in the right 
fetus and slightly to the right of the median line in the left fetus. 
Following upward this common jejunum, we find that it continues 
single almost up to the stomachs, where it joins a horizontal loop 
made up of the two short duodena. This is shown in the diagram of 
the intestinal tract. 

We see, then, that in regard to the two important systems, viz., 
the circulatory and the alimentary, the twins are very closely con- 
nected. The viability of such a monster, even if it could have been 
delivered at term, seems very unlikely. We have spoken of the speci- 
men as the "Siamese twins," but the two cases are really not very 
similar, since the Siamese twins were joined only by a band which 




Fig. 2. — The dissection of thorax and abdomen. 




A ?, 



j 5 i 

- u •+- 

_ '-C c 

~ £ S 




01 — 



J 3 



ANATOMICAL STUDY OF A THORACOPAGUS 323 

measured a few inches in diameter when they had reached adult life. 
It contained, however, a narrow band of liver. They lived to be 
sixty-three years old. 

The underlying causes of the production of such monsters are, of 
course, far from settled. Experimental teratology surely is an in- 
teresting study, but so far it has been confined chiefly to lower animals, 
e.g., the production of double tadpoles by tying a fine thread about 
the egg, or of spina bifida and cyclopia by subjecting normal fish-eggs 
to the action of sodium salts. These and similar experiments tend to 
show that the production of monsters is the result of external caus- 
ation. It is believed that the same holds good for human pathological 
embryos and monsters. 

F. P. Mall calls attention to the fact that whereas only 0.7 per cent 
of all pregnancies end in the production of pathological ova, in tubal 
pregnancies 96 per cent become pathological or produce monsters; 
and the data of von Winkel of 87 live fetuses removed from ruptured 
tubal pregnancies show that only 8 were really normal. 

Professor Mall concludes from this and from experimental tera- 
tology that the cause of the production of monsters is not germinal, 
i.e., inherent in the ovum or sperm, but is the result of external in- 
fluences. His 33 cases of pathological human ova, he finds, can be 
classified in three groups: in the first group of 11 cases, a severe 
hemorrhage for several days preceded the abortion ; the second group 
of 12 specimens were abortions from newly married women or rela- 
tively sterile women who had been married for some time; and the 
third group of 10 specimens were from women who had given birth 
to a number of healthy children and then began to abort, often two 
or three times. This last group showed that the cause could not have 
been germinal, because these women had previously borne normal 
children. The explanation is rather that the uterus was at first 
normal, but later became pathological, so that the fertilized ovum 
could not implant itself properly, but was aborted. 

In this connection it is interesting to note that the case we have 
been considering was that of a woman, aged 33, married 7 years, who 
had had two children, followed by three abortions, the last of which 
was preceded by a metrorrhagia lasting three months. And it may 
be added that this patient returned to the hospital in January, 1912, 
about a year after her last abortion, presenting again the symptoms 
of threatened abortion, but left after a week, the pregnancy not hav- 
ing been interrupted. 



REPORT OF THE PATHOLOGICAL DEPARTMENT OF ST. 
LUKE'S HOSPITAL FOR THE YEAR 1911. 

F. C. Wood, M.D., Director. 

The following abbreviated report gives the statistical results of the 

work done in the various laboratories of the department during the 
year. 

DIVISION OF SURGICAL PATHOLOGY. 

In the course of the year 762 specimens of tissue were examined 
histologically. The diagnoses were as follows : 

TUMORS. 

Adenocarcinoma of abdomen 1 

Adenocarcinoma of breast 1 

Adenocarcinoma of colon 3 

Adenocarcinoma of ovary 1 

Adenocarcinoma of rectum 6 

Adenocarcinoma of stomach 1 

Adenocarcinoma of uterus 5 

Adenomyoma of uterus 1 

Carcinoma of antrum 1 

Carcinoma of abdominal wall 1 

Carcinoma of breast 34 

Carcinoma of cervix uteri 2 

Carcinoma of jaw 1 

Carcinoma of lymph nodes 2 

Carcinoma of neck 1 

Carcinoma of omentum 2 

Carcinoma of ovary 5 

Carcinoma of peritoneum 1 

Carcinoma of prostate 1 

Carcinoma of rectum 2 

Carcinoma of sternum 1 

Carcinoma of stomach 1 

Carcinoma of tonsil 1 

324 



REPORT OF PATHOLOGICAL DEPARTMENT 325 

TTJMOBS — Cont. 

Carcinoma, gelatinous, of caput coli 1 

Carcinoma, gelatinous, of omentum 1 

Carcinoma, gelatinous, of ovary 1 

Carcinoma, gelatinous, of rectum 3 

Carcinoma, squamous cell, of urinary bladder 1 

Cystadenoma of breast 6 

Cystadenoma of ovary 3 

Cystoma of ovary 1 

Cystoma of peritoneum 1 

Cystoma, multilocular mucinous, of ovary 1 



Ep 
Ep 
Ep 

Ep 
Ep 
Ep 
Ep 
Ep 
Ep 
Ep 
Ep 



thelioma of ala nasi 1 

thelioma of cervix uteri 7 

thelioma of cheek and face 6 

thelioma of conjunctiva 1 

thelioma of esophagus 1 

thelioma of eyelid 2 

thelioma of groin 1 

thelioma of hand 2 

thelioma of jaw 2 

thelioma of larynx 1 

thelioma of lip & 



Epithelioma of lymph nodes 5 

Epithelioma of mouth 1 

Epithelioma of neck 2 

Epithelioma of pharynx 1 

Epithelioma of scalp I 

Epithelioma of tongue 4 

Epithelioma of vulva 1 

Epithelioma, basal cell, of face 4 

Epithelioma, basal cell, of eyelid 2 

Fibroadenoma of breast 7 

Fibroadenoma of prostate 1 

Fibroadenoma, intracanalicular, of breast 2 

Fibroma of thigh 1 

Fibroma, soft, of hand 1 

Fibromyoma of uterus 75 

Fibrosarcoma of femur 1 

Fibrosarcoma of small intestine 1 

Hemangioma of face 1 

Lipoma of arm 1 

Lipoma of back 1 

Lipoma of chest 1 

Lipoma of neck 1 

Lipoma of knee 1 

Lipoma of thigh 1 

Myxo-fibroma of ulnar nerve 1 



326 ST. LUKE'S HOSPITAL REPORTS 

tumors — Cont 

Neuro-fibro-liporna 1 

Osteoma of palate 1 

Papilloma of bladder 1 

Papilloma of face 1 

Polyp of cervix uteri 3 

Polyp of endometrium 1 

Sarcoma of abdomen 1 

Sarcoma of orbit 1 

Sarcoma of pelvis 1 

Sarcoma of spinal cord and vertebrae 1 

Sarcoma, giant cell, of jaw 1 

Sarcoma, lympbo-, of cervical nodes 1 

Sarcoma, lympbo-, of neck 1 

Sarcoma, lympbo-, of tonsil 1 

Sarcoma, lympbo-, of thorax 1 

Sarcoma, melano-, of ovary, breast and peritoneum 1 

Sarcoma, myxo-, of foot 1 

Sarcoma, osteo-, of tibia 1 

CYSTS. 

Dermoid cyst of ovary 7 

Epidermoid cyst of neck 1 

Follicular cyst of ovary 2 

Parovarian cyst 4 

Perinephritic cyst 1 

Sebaceous cyst of scalp 1 

Strangulated ovarian cyst 1 

MISCELLANEOUS TISSUES. 

BEPBODUCTIVE SYSTEM — FEMALE. 

Corpus luteum 1 

Decidua and Chorionic Villi 18 

Ectopic gestation 10 

Endocervicitis, glandular 7 

Endometrium, normal 9 

Endometrium, atrophy of 3 

Endometrium, hyperplasia of 21 

Endometrium, edema of 6 

Endometrium, menstrual 4 

Endometrium, premenstrual 2 

Endometritis, chronic 4 

Endometritis, interstitial 6 

Fallopian tubes, normal 11 



REPORT OF PATHOLOGICAL DEPARTMENT 327 

REPRODUCTIVE SYSTEM — FEMALE — Cont. 

Fallopian tubes, atrophy of 2 

Hematosalpinx 1 

Galactocele 1 

Hydrosalpinx 2 

Mastitis, acute 1 

Mastitis, chronic 3 

Mastitis, tuberculous 1 

Oophoritis, subacute 1 

Oophoritis, chronic 42 

Ovary, normal 2 

Pyosalpinx 13 

Salpingitis, acute 7 

Salpingitis, chronic 20 

Salpingitis, subacute 10 

Salpingitis, tuberculous 2 

Salpingo-oophoritis, acute 6 

Salpingo-oophoritis, chronic 26 

Salpingo-oophoritis, subacute 7 

Sinus of breast 1 

Tubo-ovarian abscess 5 

Uterus, tubes and ovaries, tuberculosis of 1 

REPRODUCTIVE SYSTEM — MALE. 

Epididymis, tuberculosis of 2 

Prostate, adenomatous hyperplasia of 1 

Prostate, hypertrophy of 2 

Prostatitis, subdurative 1 

Testicle, tuberculosis of 2 

GASTROINTESTINAL SYSTEM. 

Appendicitis, acute 15 

Appendicitis, catarrhal 4 

Appendicitis, chronic 26 

Appendicitis, subacute 6 

Appendicitis, peri- 1 

Appendicitis, tuberculous 1 

Appendix, normal 3 

Cholecystitis, acute 2 

Cholecystitis, chronic 6 

Cholecystitis, subacute 2 

Colitis, acute 1 

Peritonitis, acute 4 

Peritonitis, subacute 1 

Peritonitis, tuberculous 2 



328 ST. LUKE'S HOSPITAL REPORTS 

GASTBOINTE8TINAL SYSTEM — Cont 

Thrombosed vein of intestine 1 

Tonsil, chronic inflammation of 3" 

Tonsil, normal 1 

Tonsil, tuberculosis of 1 

TTRINABY SYSTEM. 

i 

Kidney, multiple abscesses of 1 

Kidney, tuberculosis of 3 

Hemorrhage into kidney, site not discovered 1 

Hydronephrosis 2 

Pyonephrosis 1 

Nephritis, suppurative 3 

BONES AND JOINTS. 

Osteitis 1 

Osteitis, productive 1 

Osteitis, rarefying and productive 1 

Osteomyelitis, chronic 4 

Osteomyelitis, tuberculous 3 

Synovitis, chronic 1 

Tuberculosis of carpal bones 1 

Tuberculosis of chest wall 1 

Tuberculosis of femur 1 

Tuberculosis of knee 1 

LYMPH NODES 

Adenitis, simple 4 

Adenitis, tuberculous 29 

Nodes, chronic hyperplasia of 3 

Nodes, normal 1 

MISCELLANEOUS. 

Abscesses of liver, miliary 1 

Actinomycosis of abdomen 1 

Blood clot 6 

Cartilage 1 

Connective tissue 8 

Connective tissue, inflamed 11 

Corneal ulcer 1 

Endarteritis, with gangrene of foot 1 

Fibrin 3 

Furuncle 1 



REPORT OF PATHOLOGICAL DEPARTMENT 329 

MISCELLANEOUS — Cont. 

Gangrene of thumb, diabetic 1 

Goitre, colloid 8 

Goitre, exophthalmic 1 

Granulation tissue, simple 11 

Granulation tissue, tuberculous 4 

Hemorrhoids, inflamed granulation tissue 1 

Iridocyclitis 1 

Mucous membrane, normal 1 

Myositis 3 

Nasal polyp 2 

Panophthalmitis, chronic 1 

Pigmented mole of abdomen 1 

Salivary glands, normal 1 

Sebaceous cyst, chronic inflammation of 1 

Tuberculosis of intercostal tissue 1 

Ulcer of leg 1 

POST-MORTEM EXAMINATIONS. 

During the past year fifty-three autopsies have been performed. 
Several of the more interesting cases are reported at length elsewhere. 

840. Anatomical Diagnosis: Acute aortitis. Chronic fibrous myocarditis, 
with cardiac hypertrophy and dilatation, and relative mitral and tricuspid 
insufficiency. Healed tuberculosis of lungs, with passive congestion. Chronic 
diffuse nephritis. Chronic passive congestion of liver and spleen. 

841. Case of sudden death, a child, twelve years of age, in the hospital 
for tuberculosis of spine, hip and both knees. Besides the above tuberculous 
conditions, the autopsy showed a very large thymus extending from the thyroid 
gland to within one inch of lower border of heart. The left lateral lobe passed 
down over the left side of heart in a thin, flat layer. The mesenteric and 
transverse mesocolic nodes were enlarged, and there was hyperplasia of the 
lymphoid nodules throughout the intestine. 

842. Anatomical Diagnosis : Subdural hemorrhage. Multiple cerebral and 
cerebellar hemorrhages. General arteriosclerosis. Coronary sclerosis. Cardiac 
hypertrophy. Healed tuberculosis of lungs. Chronic adhesive pleurisy. Chronic 
diffuse nephritis. 

843. Anatomical Diagnosis: Epithelioma of cervix, with extension to 
pelvic and inguinal lymph nodes and left iliac vein. Metastases to spleen and 
lung. Thrombosis of cerebral veins and softening of right hemisphere. Double 
hydrothorax. Anemia of viscera. 

844. Anatomical Diagnosis : Acute fibrino-purulent pericarditis and empy- 
ema. Acute bronchopneumonia. General lymphatic hyperplasia. Cloudy swell- 
ing of liver and kidneys, with congestion. Acute splenic tumor. Culture 
from pericardial exudate showed pneumococcus. 



330 ST. LUKE'S HOSPITAL REPORTS 

845. Case of corrosive sublimate poisoning. Partial autopsy. Anatomical 
diagnosis : Acute parenchymatous nephritis. 

846. Anatomical Diagnosis : Chronic mitral endocarditis, with acute 
exacerbation. Auricular thrombosis. Hypertrophy of heart, dilatation of 
auricles. Infarction of lung. Hydrothorax. Atelectasis of lung. Healed 
tuberculosis of lungs. Acute ulcerative aortitis. Chronic diffuse nephritis 
(chiefly parenchymatous). Chronic passive congestion of liver, spleen and 
intestine. Chronic gastritis. Chronic interstitial pancreatitis. Edema of 
cerebral pia mater. Cystic degeneration of left lenticular nucleus (old soft- 
ening). 

847. Anatomical Diagnosis : Chronic diffuse nephritis. Cardiac hyper- 
trophy. Edema of lungs. Ulcerative laryngitis and pharyngitis. Acute splenic 
tumor. Fatty degeneration of liver. Chronic cystitis. 

848. Anatomical Diagnosis : Chronic interstitial nephritis of severe grade. 
Practically no other changes. Moderate hypertrophy of left ventricle. 

849. Anatomical Diagnosis : Tuberculous meningitis. General miliary tu- 
berculosis. Perforating appendicitis. General purulent peritonitis. 

850. Anatomical Diagnosis : Lobar pneumonia of right upper, middle, and 
part of lower lobe. Congestion and chronic tuberculosis of both lungs. Chronic 
adhesive pleuritis and pericarditis. Cloudy swelling of liver and kidneys. 
Edema of pia. 

851. Anatomical Diagnosis : Arteriosclerosis. Cylindrical aneurism of 
aorta. Chronic myocarditis. Double hydrothorax. Congestion, edema, and 
healed tuberculosis of lungs. Passive congestion of liver, spleen and intestine. 
Slight chronic diffuse nephritis. Meckel's diverticulum. 

852. Anatomical Diagnosis : False aneurism of aorta, with rupture into 
left pfeura. Fusiform and dissecting aneurisms of aorta. Extreme aortitis. 
Edema and congestion of lungs. Subacute serofibrinous pleurisy. Aortic 
insufficiency and cardiac hypertrophy. Passive congestion of liver, spleen 
and kidneys. 

853. Anatomical Diagnosis : Acute vegetative endocarditis, involving mi- 
tral, aortic and tricuspid valves. Free thrombus in right auricle. Acute 
serofibrinous pericarditis and pleurisy. Mitral insufficiency and dilatation of 
right auricle. Edema of lungs. Passive congestion of heart, liver, spleen 
and kidney. 

Bacterial Diagnosis: Smears from mitral valve and from pericardium 
show Gram-positive diplococci resembling pneumococci. Cultures show similar 
organisms in mixed culture. 

854. Partial Autopsy. Anatomical Diagnosis : Acute ulcerative colitis. 
Etiology not determined. 

855. Anatomical Diagnosis: Chronic pulmonary tuberculosis. Cavity in 
right lower lobe. Acute mitral endocarditis. Acute splenic tumor. Chronic 
hyperplasia of lymph nodes. (Death occurred after diabetic coma.) 

850. Anatomical Diagnosis : Chronic endocarditis, with ball thrombus in 
right auricle. Thrombosis of right vertebral artery, with softening in medulla. 
Infarct of spleen. Chronic passive congestion of lungs and liver. 

857. Anatomical Diagnosis : Microgyria, with secondary external and 
internal hydrocephalus ex vacuo. Bronchopneumonia. 



REPORT OF PATHOLOGICAL DEPARTMENT 331 

858. Partial Autopsy. Anatomical Diagnosis: Cholelithiasis of common 
duct. Bacillus aerogenes capsulatus infection of sinus and liver, and septi- 
cemia following cholecystectomy. 

859. Anatomical Diagnosis: Bronchopneumonia. Fibrinopurulent pleu- 
ritis. 

860. Anatomical Diagnosis : Chronic mitral endocarditis. Fatty degenera- 
tion of heart. Tuberculosis of bronchial nodes. Fatty degeneration of liver. 
Hydrosalpinx. Cystic ovaries. Fibromyoma of uterus. 

861. Anatomical Diagnosis: Chronic fibrous pleuritis. Tuberculosis of 
the lungs. Tuberculosis of bronchial lymph nodes. Bronchopneumonia. En- 
docarditis, acute mitral. Chronic diffuse nephritis. Ulceration (typhoid) of 
ileum, cecum and colon. Hyperplasia of lymph nodules and Peyer's patches 
of ileum. Hyperplasia of mesenteric nodes. Congestion and hyperplasia of 
spleen. 

862. Anatomical Diagnosis : Chronic fibrous pleurisy. Healed tuberculosis 
of lungs. Carcinoma of lesser curvature of stomach, with perforation. Metas- 
tases in liver, pancreas, mesenteric lymph nodes and sigmoid, involving blad- 
der wall. Acute peritonitis. Chronic diffuse nephritis. 

863. Anatomical Diagnosis : Acute colitis. ■ '• 

864. Anatomical Diagnosis: Bronchopneumonia. Acute enteritis. 

865. Partial Autopsy : Glioma, with softening, of floor of fourth ventricle. 

866. Anatomical Diagnosis : Acute vegetative endocarditis. Bronchopneu- 
monia of left upper lobe. Cyst of brain partially replacing lenticular nucleus 
and anterior limb of internal capsule on right side. Cloudy swelling of 
kidneys. 

867. Anatomical Diagnosis : Acute hemorrhagic pancreatitis. Acute chole- 
dochitis. Multiple areas of old necrosis in and about the pancreas. Fatty 
degeneration of the liver. Tuberculosis of the liver. 

868. Anatomical Diagnosis : Sarcoma of retroperitoneal region, with me- 
tastases in kidneys, lymph nodes, and subcutaneous tissue. Left pyonephrosis. 
Atrophy and dilatation of heart. Passive congestion of spleen and liver.. 
Edema of lungs. Anasarca of legs and hips, due to blocking of inferior vena 
cava and left common iliac veins. Chronic cystitis. Compensatory hyperplasia 
of bone marrow. 

869. Anatomical Diagnosis : Chronic fibrous pleurisy. Lobar pneumonia. 
Healed pulmonary tuberculosis. Chronic diffuse nephritis. 

870. Anatomical Diagnosis : Umbilical hernia. Umbilical fistula. Ascites. 
Acute peritonitis. Cirrhosis of liver. Chronic passive congestion of spleen. 
Chronic diffuse nephritis. Chronic endocarditis. Aortic stenosis. 

871. Anatomical Diagnosis : Acute ulcerative endocarditis of the aortic 
and mitral valves. Cardiac hypertrophy and dilatation. Hydropericardium. 
Double hydrothorax and ascites. Edema and chronic tuberculosis of lungs. 
Infarct of spleen. Parenchymatous degeneration of left kidney. Chronic pas- 
sive congestion and hemangioma of liver. Chronic seminovesiculitis. 

872. Partial Autopsy. Anatomical Diagnosis : Hyperplasia and ulceration 
of Peyer's patches and lymph follicles of ileum, cecum and colon (typhoid). 
Perforation of ileum. Hyperplasia of mesenteric nodes. General peritonitis. 

873. Case of man 45 years of age, who had been troubled for nine months 



332 ST. LUKE'S HOSPITAL REPORTS 

previous to entering hospital with difficulty in swallowing, and pain in chest, 
of indefinite localization. He had lost nine pounds in two months. Three weeks 
after entrance, the patient vomited three ounces of blood, grew gradually 
weaker, and died in five hours. At autopsy, a tumor was found projecting 
into the esophagus from its anterior wall, about 1 cm. above the level of the 
bifurcation of the trachea, the lumen thus being narrowed so as just to admit 
the passage of the index finger. From this point to about 1 cm. above the 
cardiac orifice of the stomach, the entire mucosa and a considerable portion 
of the walls of the esophagus were destroyed, a large cavity being formed in 
the posterior mediastinum, bounded by soft necrotic tissue. At the level of 
the fourth intercostal artery the wall of the aorta, over an area about 2 cm. 
in diameter, was destroyed nearly to the intima. The fourth right intercostal 
artery was torn from the aorta, and its point of exit marked by a small 
perforation about 2 mm. in diameter, leading directly into the esophagus. The 
stomach contained one liter of clotted blood. There were metastases in the 
pancreas and liver. Microscopical examination showed the tumor to be an 
epithelioma. 

874. Anatomical Diagnosis: Double hydrothorax. Pericarditis. Cardiac 
hypertrophy. Chronic endocarditis. Mural thrombus in right auricle. Rup- 
ture of chordae of anterior cusp of mitral valve. Infarction of both lungs. 
Chronic adhesive peritonitis. Chronic passive congestion of liver and spleen. 

875. Anatomical Diagnosis : Double hydrothorax. Acute and chronic en- 
docarditis. Aortic stenosis and insufficiency. Cardiac hypertrophy. Chronic 
diffuse nephritis. Sclerosis of coronaries and aorta. 

876. Anatomical Diagnosis : Chronic ulcerative colitis. Chronic parenchy- 
matous nephritis. Left bronchopneumonia. Miliary abscesses of both lungs. 
Subacute cholecystitis. Multiple ulcers of skin. 

877. Partial Autopsy. Anatomical Diagnosis: Operative skull defect. 
Local meningitis. New growth of cerebellum and cyst communicating with 
aqueduct of Sylvius. Compression of fourth ventricle. Internal hydro- 
cephalus. 

878. Anatomical Diagnosis: Tuberculosis of lungs. Chronic adhesive 
pleurisy. Miliary tuberculosis of liver and spleen. Chronic diffuse nephritis. 
Thrombosis of right femoral vein. Arteriosclerosis. 

879. Case of a woman 23 years of age, entering hospital in moribund 
condition. No history was obtained, except that she had had a headache and 
backache for eight days, with temperature varying from 101° to 103°. She is 
said to have coughed considerably for some time, the expectoration being at 
times bloody, but never to have had heart trouble until three weeks before, 
when she began to complain of shortness of breath. The autopsy findings 
were interesting on account of the extreme grade of congenital pulmonary 
stenosis, the orifice, 2.7 cm. in circumference, barely admitting the tip of the 
little finger. The right auricle and ventricle were greatly hypertrophied, the 
right ventricular wall measuring 2.3 cm. in thickness. The left auricle and 
ventricle were both small. The left ventricular wall measured 1.5 cm. Neither 
the foramen ovale nor the ductus arteriosus were patent. There were three 
small, apparently recent, vegetations on one cusp of the pulmonary valve. 
The lungs showed healed tuberculous lesions and two areas of infarction in 



REPORT OF PATHOLOGICAL DEPARTMENT 333 

the right lower lobe and one in the left. The liver and spleen showed the 
effects of chronic passive congestion. 

880. Anatomical Diagnosis : Chronic endocarditis. Mitral stenosis. Car- 
diac hypertrophy and dilatation. Edema, ascites and double hydrothorax. 
Chronic passive congestion of liver, spleen and kidneys. 

881. Partial Autopsy. Anatomical Diagnosis: Tuberculous enteritis and 
localized peritonitis. Amyloid degeneration of spleen. Chronic parenchyma- 
tous degeneration of spleen. Passive congestion of liver. 

882. Anatomical Diagnosis : Carcinoma of stomach. Metastases in liver, 
spleen, retroperitoneal and posterior mediastinal lymph nodes. Mural throm- 
bus of left ventricle. Septic thrombus of right pulmonary artery, with septic 
infarct of lung and acute fibrinopurulent pleurisy. Left hydrothorax. Edema 
of lungs. Chronic diffuse nephritis. 

883. Anatomical Diagnosis : Edema of legs. Right hydrothorax. Chronic 
adhesive pleurisy. Chronic adhesive pericarditis. Gumma of heart wall. Car- 
diac hypertrophy. Aneurism of aorta, ascending and transverse portion. Arte- 
riosclerosis. Edema of lungs. Gummata of liver. Atrophy of left lobe of 
liver. Gall stones. Chronic passive congestion of liver, spleen and kidneys. 

884. Partial Autopsy. Anatomical Diagnosis : Carcinoma of the bronchi, 
with metastases in pleura, liver, kidney and peritoneum. 

885. Anatomical Diagnosis : Double hydrothorax. Acute pericarditis. Car- 
diac hypertrophy. Edema of lungs. Chronic passive congestion of liver and 
spleen. Chronic interstitial nephritis. Colitis. 

886. Anatomical Diagnosis: Chronic diffuse nephritis. Hypertrophy of 
the heart. Arteriosclerosis. Right bronchopneumonia. Petechial hemorrhages 
in intestines. 

887. Anatomical Diagnosis: Chronic adhesive pleurisy. Edema of lungs. 
Ulcerative colitis. Ethmoiditis. 

888. Anatomical Diagnosis. Lobar pneumonia of right lower and middle 
lobes and left lower lobe. Double fibrinopurulent pleurisy. Cloudy swelling 
of kidneys. 

889. Anatomical Diagnosis : Infected wound of wrist. Acute axillary 
adenitis. Bronchopneumonia. Infarction of spleen. General lymphatic hyper- 
plasia. Cloudy swelling of kidneys. Smears from axillary nodes show Gram- 
positive cocci in chains. Similar organism in lung. 

890. Anatomical Diagnosis : Chronic adhesive pleurisy. Peritonitis. Fatty 
degeneration of liver. Acute hemorrhagic pancreatitis. 

891. Partial Autopsy. Anatomical Diagnosis : Carcinoma of breast. Me- 
tastatic carcinoma of ribs, left femur (with fracture of femur), and spleen. 

892. Anatomical Diagnosis : Lobar pneumonia of right upper lobe. Acute 
fibrinous pleurisy. Healed pulmonary tuberculosis. 



DIVISION OF BACTERIOLOGY. 

The routine bacteriological examinations made during the year may 
be classified as follows: 



334 ST. LUKE'S HOSPITAL REPORTS 

Blood Cultures: 

Typhoid bacillus 28 

Streptococcus 11 

Staphylococcus 4 

Pneumococcus 4 

Negative 129 

Total 176 

Urine Cultures : 

Colon bacillus 27 

Typhoid bacillus 2 

Staphylococcus 3 

Streptococcus 2 

Mixed cultures 8 

Negative 38 

Total 80 

Throat Cultures for diphtheria bacillus : 

Positive 104 

Negative 233 

Total 337 

Miscellaneous Cultures 189 

Smears examined for tubercle bacillus: 

Sputum Positive 158 

Negative 479 

637 

Urine Positive 2 

Negative 40 

42 

Chest and abdominal fluids. .Positive 1 

Negative 5 

6 

Spinal fluid Positive 10 

Negative 24 

34 

Stools Positive 2 

Negative 2 

4 

723 

Guinea-pigs inoculated for tubercle bacillus. .Positive 9 

Negative 45 

54 



REPORT OF PATHOLOGICAL DEPARTMENT 335 

Guinea-pigs inoculated for diphtheria bacillus 23 

Mice inoculated 28 

Vaginal smears examined for gonococeus 481 

Urethral smears examined for gonococeus 60 

Miscellaneous smears examined 197 

The only serological examinations which have been made in any 
number are the Wassermann and Widal reactions : 

Wassermann reaction 597 

Widal reaction 312 

DIVISION OF CLINICAL PATHOLOGY. 

The following routine specimens were examined during the year : 

Abdominal fluids 26 

Blood : Estimation of coagulation time IS 

" " hemoglobin 898 

" " red cells 582 

" " white cells 3,780 

Examination for malarial parasites 77 

" filaria 5 

" " trichinellae 2 

Chest fluids 94 

Duodenal contents 4 

Gastric contents 254 

Glyco-tryptophan tests 4 

Spinal fluids : Total and differential counts 31 

Butyric acid tests 6 

Stools 381 

Urines 23,780. 



Roentgen Ray Laboratory 



DER 



dby 
dark 
aent, 
died, 
the 



PLANS OF THE ROENTGEN RAY LABORATORY, UNDER 

CONSTRUCTION ON THE THIRD FLOOR OF THE 

TRAVERS PAVILION, ST. LUKE'S HOSPITAL. 

Leon Theodobe Le Wald, M.D. 

Protection for the patients and the operators has been secured by 
the use of X-Ray-proof partitions and steel doors. Access to the dark 
room will be through a labyrinth, and a method of tank-development, 
which will accommodate the largest sized plates, will be installed. 
Room for expansion of the laboratory has been reserved on the 
same floor. 

The plans appear on the two succeeding pages of this report. 



339 



REPORT OF A CASE OF DILATATION OF THE STOMACH. 

MEDICAL TREATMENT. RECOVERY RECORDED 

BY MEANS OF THE X-RAY. 

Leon Theodore LeWald, M.D. 

The following ease appears to be worth reporting on account of the 
striking result of treatment, and the graphic record of this result as 
shown by the X-Ray examination. 

Miss A. 0., aged 21, a telephone operator by occupation, was 
admitted to the service of Dr. Austin W. Hollis on February 24, 1912, 
suffering from "chronic stomach trouble." Her family history was 
negative. She had had the usual diseases of childhood, and at the 
age of seven she first showed symptoms relevant to her trouble on 
admission. At that time she had been seized, while playing, with an 
attack of vomiting. There was no nausea, either before or after the 
attack, and the patient went on playing entirely undisturbed. For 
three months thereafter, each meal was followed immediately by an 
attack of vomiting, which was sometimes projectile in character, some- 
times not. Occasionally the patient was nauseated. The stomach was 
not emptied at once, but the vomiting would continue at intervals for 
as much as five hours after each meal, being increased by any exertion 
and allayed by keeping quiet. A cramplike pain in the epigastrium 
with soreness and tenderness in this region accompanied the vomiting. 

At first these attacks had occurred at intervals of four or five 
months, and lasted from two to three months, the patient's skin being 
dry and yellow and her bowels constipated throughout the period of 
disturbance. Recently the attacks had been more frequent, occurring 
every two or three months, with especial severity in spring and fall. 

The attack which occasioned the patient's entrance to St. Luke's 
began two weeks previous to admission with severe and unremitting 
headache in the right occipital region. A week before admission 
vomiting recommenced, accompanied by nausea. Six months previous 
to this admission the patient had been operated on at St. Luke's for 
appendicitis. The physical examination made on her present entrance 
was negative, except for a slight general tenderness of the abdomen 
on deep pressure. 

The X-Ray examination made on March 4, 1912, showed the stomach 
dilated and the greater curvature 4% inches below the umbilicus. The 
stomach was not empty in 6 hours. The colon was sluggish. 

The course of treatment consisted mainly of rest in bed, with daily 
lavage and a restricted diet, chiefly protein. On March 27th, one 

340 



X-RAY OF DILATED STOMACH 341 

month after admission, the patient had apparently regained her health, 
and could now eat without nausea or discomfort. The second X-Ray 
examination, made for the purpose of determining the condition of the 
stomach after treatment, shows in a very striking manner that the 
stomach has regained its tone. The dilatation has disappeared; the 
greater curvature has retracted so that it is only one inch below the 
umbilicus in contrast to the four and a half inches shown before treat- 
ment. The size and position are within normal limits, so that a very 
good prognosis can be offered as to continued good health if ordinary 
care is exercised. A further examination shows that the stomach 
empties itself in normal time. The tone of the colon has also improved, 
so that the tendency to constipation has been relieved. 



Out- Patient Department 



PRACTICAL NOTES FROM THE SURGICAL DIVISION OP 
THE OUT-PATIENT DEPARTMENT. 

William S. Thomas, M.D. 

The intention of this paper is to present a number of procedures 
in frequent use in the Surgical Division of the 0. P. D., with com- 
ments upon the result of experience with them. 

The subjects considered will be as follows : 

1. Nitrous oxide anesthesia. 

2. Use of picric acid in burns. 

3. Removal of foreign bodies from the tissues. 

4. Use of scarlet red on ulcers. 

5. Open treatment of fractures. 

6. Mode of demonstrating lesion of anal region. 

7. Rigid supporters for varicosities. 

8. Enucleation of tonsils. 

9. Spring retractors. 

1. Nitrous Oxide Anesthesia. — Nitrous oxide gas, with oyxgen, 
in the past 3 years has been coming into very frequent use in our 
minor surgical work. It has so far supplanted ether and chloroform 
that, without statistics before me, I feel safe in saying that where 
one of the latter was administered 10 times 3 or 4 years ago, it 
is not used more than once now. Nitrous oxide gas has proved es- 
pecially useful in the diagnosis of treatment of b6ne fractures and its 
use permits careful and painless manual examination in almost every 
case. It seems as though patients were entitled to its benefit. It is 
contraindicated or ineffectual in the cases of very young patients, pa- 
tients with severe organic cardio-vascular diseases, and alcoholics. 

In the case of alcoholism, rather than struggle to anestheticize a 
patient with gas or ether alone, it is frequently found quite feasible 
to attain relaxation and insensibility if the gas is preceded by a hypo- 
dermic of morphine. The particular advantage of this short an- 
esthesia and rapid awakening without nausea or sickness in the case 
of ambulatory patients is obvious. 

345 



346 ST. LUKE'S HOSPITAL REPORTS 

2. Use op Picric Acid in Burns. — The use of this acid in super- 
ficial burns was begun in the surgical clinic in 1907, and has proven 
to be a distinct advance over old procedures. At first, used as an 
ointment, later in hypersaturated solutions, it was found to have a 
poisonous effect if used on large surfaces. Its best manner of use 
seems to be as a wet dressing in watery solutions of one-half of 1 
per cent. In burns of the first and second degree, pain is relieved, 
the serous effusion ceases and the growth of epithelium is enhanced. 
The principal disadvantage of the remedy is its ability to stain every- 
thing yellow with which it comes in contact. 

3. Foreign Bodies. — Bits of steel, fragments of glass, wooden 
splinters, but especially fragments of sewing-needles, lost under the 
skin, are very common in any minor surgical clinic, and frequently 
prove to be difficult of removal. After free incision, and guided by a 
skiagram made immediately before, there is no doubt that the most 
important aid in discovering these lost fragments is the sense of 
touch. In the case of metallic foreign bodies material assistance has 
been afforded in our clinic by the telephonic searcher described in 
the bulletin of last year, which is in steady use, and is made by 
Wappler. When a metallic foreign body is located in a finger or toe 
or in the webs between them, its shadow may often be seen in the 
dark room by transillumination with a small electric light shielded 
on all sides but one, as is used for the illumination of the accessory 
sinuses of the nose. Elsewhere, these lights are of no use. When 
used to demonstrate a foreign body in a finger or toe the light must 
be applied to that side farthermost from the foreign body. In other 
words, the foreign body must lie nearest to the skin next the observer's 
eye or it cannot be seen. 

4. Scarlet Red. — The extended use of this dye as a dressing for 
granulating surfaces has demonstrated that it has a field of usefulness. 
In our experience, corroborated by control experiments, it has been 
shown to hasten the growth of epithelium upon healthy surfaces. In 
the case of varicose, or infected ulcers, where there is no previous 
tendency to heal, scarlet red alone is worse than useless. It seems 
to have no antiseptic power. 

5. Open Treatment of Fracture. — Continued use of the metallic 
plate in selected cases of fracture confirms the good opinion of this 
surgical procedure. It is seldom necessary, however, and the indi- 
cations for the method seem to be clearly the following : Impossibility 
of fairly good reduction of deformity, rotation deformity of radius, 



SURGICAL NOTES FROM THE O. P. D. 347 

mal-union and persistent non-union. Careful asepsis and avoidance 
of traumatism, when operating, are necessary. Lane's steel plates 
require a considerable outlay for a full set and cannot always be ob- 
tained. Sheet aluminium is cheap, and may be easily obtained at 
wholesale hardware stores and fashioned into the proper form for 
internal splints in a few minutes, to suit the exigencies of each case. 
The writer described the use of such plates in the Bulletin of 2 years 
ago. In an experience of 3 years with the use of aluminium plates, 
no serious cases of infection have been encountered. In 2 patients 
there was enough infection to make it necessary to remove the plates 
in order to cure a sinus, but in both of these cases the ultimate result 
of the operation was perfectly good. 

6. Mode of Demonstrating Lesion of Anal Region. — Ever since 
suction cups have been used as recommended by Bier in his hyper- 
emia treatment, we have turned this method of producing a partial 
vacuum to use in certain rectal conditions. With the patient in a 
lithotomy position, a suction cup of a diameter of 1% to 2y 2 inches, 
and properly curved, is applied over the anus and the air exhausted. 
Any external hemorrhoidal conditions will be exaggerated and plainly 
visible where they might otherwise be obscured by horizontal posture 
of the patient. In the case of internal hemorrhoid or a fissure or of 
a lesion within the first inch of the rectum, suction with a cup will 
evert the rectal mucous membrane in such a manner that hemor- 
rhoids will stand out more distinctly and the mucous membrane of 
the whole circumference of the bowel will be brought into view. 

7. Rigid Supporters for Varicosities. — The day of the elastic sup- 
porter for slack abdominal walls and misplaced viscera is past, or 
ought to be. In like manner the elastic stocking for the support of 
the leg has at last found a rival in rigid appliances. A writer in the 
New York State Medical Journal has recommended the use of adhesive 
strapping of the whole leg in cases of varicose ulcer; and Dr. John 
B. Murphy, of Chicago, in the Journal of the American Medical As- 
sociation of March 27, 1909, recommended the use of inelastic leggings 
in varicose ulcers. A mode of procedure in use in the Medical Di- 
vision of the 0. P. D. was to treat varicose leg ulcers by adhesive 
strapping from the toes to the knee, omitting the sole, and after the 
ulcer is cured to have made a muslin corset for the leg to prevent re- 
currence. The strapping is of strips about one-half inch wide, ap- 
plied obliquely in two directions and crossing each other so as to 
leave openings of regular intervals, like a checker-board. This strap- 



348 ST. LUKE'S HOSPITAL REPORTS 

ping is left on about a week, with a pad of gauze over the ulcer and 
the usual bandage over the whole, changed as frequently as neces- 
sary. The method is not applied when there is a phlebitis, or where 
the skin is much macerated or eczematous, or where the ulcer is be- 
hind or below the ankle. The method seems to have given most en- 
couraging results in these cases, which have long been considered the 
bane of every minor surgical clinic. 

8. Enucleation of Tonsils. — For the past 4 years it has been 
our practice to enucleate the tonsils in practically every case oper- 
ated upon. Only in cases where the tonsil projects far into the 
pharynx and is not covered by the interior pillar of the fauces has the 
guillotine been used without a preliminary dissection of the tonsil 
from its bed. The procedure ordinarily employed requires complete 
anesthesia, but is very simple. In children, where the tonsil has not 
been the seat of a fibroid degeneration, to make it abnormally ad- 
herent to its surroundings, a short incision is made along the most 
prominent portion of the edge of the interior pillar. The finger is 
worked into this incision with its palmar surface toward the tonsil, 
and the latter is shelled out of its bed by blunt dissection from all 
its attachments except along its posterior aspect. At this point the 
tonsil is grasped with the sponge forceps or other convenient instru- 
ment, and the pedicle is snipped with a pair of curved scissors or 
possibly with a tonsillotime. This method is chosen rather than sharp 
dissection on account of the fact that less hemorrhage follows and be- 
cause there is less danger of cutting what is not desired to be cut. 
Routine questioning of patients in respect to possible hemophilia is 
insisted upon. In the case of weak, anaemic children, calcium salts are 
administered some days prior to the operation, in the hope of lessening 
hemorrhage. 

9. Spring Retractors. — The German silver wire self-holding re- 
tractors described in the Journal of the American Medical Association, 
in April, 1903, have been found to be of use in our operating room, 
where the desired number of assistants are not always available. 



' 



POSSIBLE CAUSES OF FAILURE FOLLOWING THE USE OF 
BACTERIAL VACCINES AND ANTISERA.* 

H. E. Plummer, M.D. 

"The most mischievous ignorance is that of the critic." So many 
unjust criticisms are heard relative to the value of bacterial vaccines 
and antiserum in the treatment of infections, that the above quotation 
of Voltaire seems scarcely out of place. Some reports indicate such 
successful results and others such absolute failures in similar cases 
that they stimulate us to inquire into the reasons for such diversity 
of conclusions. May not these failures be in part due to faulty dosage, 
to incorrect intervals elapsing between the doses, to a wrong apprecia- 
tion of the benefits to be expected from the use of a bacterial vaccine or 
antiserum, and to a faulty selection of the remedy to be used? Let 
us first study briefly the qualities of a bacterial vaccine and of an 
antiserum and the theories upon which their use is based. 

Antisera are obtained from some bacteria that do not produce ex- 
tracellular toxins in sufficient quantities : as, for example, the strepto- 
coccus and the gonococcus. The germs themselves are injected into 
the animal, first in minute doses of greatly attenuated cultures, then 
in gradually increasing doses until such a resistance exists in the ani- 
mal that large amounts are tolerated. These antisera may be said to 
possess antibacterial power. The fact that antisera are elaborated in 
the horse distinguishes them from bacterial vaccines which are simply 
suspensions of killed bacteria in physiological salt solution. From 
this it may be seen that when antisera are used the patient is inocu- 
lated with the protective substances produced by an animal, whereas 
when bacterial vaccines are injected the patient must produce his own 
protective bodies. 

Wright and others have demonstrated the fact that there are sub- 

*Read before the West Side Clinical Society. 

Note. — The vaccines used in the preparation of this article were kindly 
furnished by the Department of Experimental Medicine of Parke, Davis 
& Co. 

349 



\ 



350 ST. LUKE'S HOSPITAL REPORTS 

stances in the blood stream that assist, or are necessary to aid the 
phagocytes in their successful warfare against invading bacteria. If, 
however, Nature's laboratory is unable to completely overwhelm them 
at once, the destruction of a portion of the invading host will produce 
a strengthening of the defending force. This is known as autoin- 
oculation and is best illustrated in the pneumonic crisis. In some in- 
fections the protection afforded is lasting, as in smallpox and in yellow 
fever, while in others, as in tuberculosis, the protection is transient. 
When Nature is able to cope with the infecting bacteria, self-immun- 
ization is likely to take place. This is due to the death of a certain 
number of the organisms and their immediate effects as immunizing 
agents. The artificial introduction of a suitable number of dead 
microorganisms, i.e., the injection of a bacterial vaccine, may turn the 
scale and produce the reinforcement necessary to Nature, which at the 
moment is so urgent. As a result of the injection of these bacterial 
products such indefinite substances as bacteriolysins, precipitins, ag- 
glutinins, and opsonins are produced. The latter, which are measur- 
able, act on the bacteria in such a way as to make them more vulner- 
able to the attacks of the phagocytes. The phenomena accompanying 
spontaneous recovery from an infectious disease, and which for a time 
at least prevents a new attack, we term natural acquired active im- 
munity. That produced by the injection into the tissues of small 
quantities of living or killed microorganisms or of toxins produced 
by these organisms we call acquired active immunity. "In passive 
acquired immunity, on the other hand, the patient does little or noth- 
ing toward obtaining this immunity. The toxins, which characterize 
the disease, are simply neutralized or rendered inert by the injection 
into the individual of protective substances, which have developed in 
the serum of another animal, as the result of active immunization. 
This form of immunity is a temporary expedient, which simply serves 
to hold the disease processes in check sufficiently long to permit Na- 
ture to manufacture and bring into play such protective and bac- 
tericidal substances as will rid the individual of the offending bacteria 
and their toxins." 

The opsonic index is the comparative phagocytosis of the patient's 
serum to a normal pool serum. The technique is complicated and the 
slightest inaccuracy produces decidedly varied results. The index 
has proven of great value in indicating the proper dosage, frequency 
of injection, and results obtained. It has been found that the care- 
ful observation of the clinical symptoms acts as a sufficient guide to 



FAILURES FOLLOWING USE OF VACCINES 351 

the treatment by bacterial vaccines in the more common infections. 
By determination of the opsonic index, "Wright has demonstrated that 
following the injection of vaccines, there is first a drop in the opsonic 
index and later a rise. This drop he calls the negative phase and the 
rise the positive phase. The use of bacterial vaccines in infections is 
clearly defined. It is useless to suppose that every case of infection 
is a suitable one for this treatment. The question is of necessity 
whether the patient is capable of producing antibodies to the in- 
fecting agent or whether they should be introduced from without, i.e., 
from an animal already immunized to the infecting agent. 

A case occurs to me of a patient infected by an attenuated strain 
of streptococcus which ran a chronic course. A culture was obtained 
and an autogenous vaccine prepared and administered at intervals. 
The patient continued to grow worse and ultimately died. This pa- 
tient was already so surfeited with streptococci that the introduction 
of a few million more dead germs seemed scarcely the rational treat- 
ment for such a condition. Had such a patient the power to produce 
his own antibodies, it would appear rational that he would have pro- 
duced them with the many streptococci swarming in his system, with- 
out the introduction of more. Thus antistreptococcic serum should 
have been first used to modify the infection. Therefore, in general 
septicemias the serums are indicated; whereas in localized or semi- 
localized conditions the bacterial vaccines are to be preferred. 

In reviewing the important subject of dosage we find a great va- 
riety of opinions. There are, on the one hand, the advocates of small 
doses and, on the other, those of large doses, but no set rule can be 
laid down for the administration of bacterial vaccines. The guiding 
factor in these cases must be more or less the resistance of the in- 
dividual to the infecting organism and therefore the ability of the 
tissues of the patient to produce antibodies. Overdosage has been a 
not infrequent cause of absolute failure. It has often been noted 
that the administration of 400,000,000 staphylococci in cases of furun- 
culosis has produced an increased number of pustules or furuncles in- 
stead of benefiting the condition. In other words, there has been a 
production of a prolonged or more severe so-called negative phase, 
thereby allowing the invading bacteria to obtain the mastery over 
the protecting forces of the blood stream. During the aggravated or 
very violent stage of the infection one should not administer a vac- 
cine, as the activity of the infecting agent itself may be producing a 
negative phase. 



352 ST. LUKE'S HOSPITAL REPORTS 

No definite time can be positively made as to the proper interval 
for reinoculation, but in every case sufficient time should elapse be- 
tween injections to allow the formation of the high wave of the positive 
phase. In scarcely any instance should the interval between the ad- 
ministrations be less than 3 days or in very rare instances more than 
7 days, the average time being about 4 to 5 days. An instance has 
occurred to me in which bacterial vaccines were administered in maxi- 
mum doses daily and it was noted that the patient was gradually 
becoming worse. The treatment was therefore discontinued, and at 
the end of the second day most marked improvement was observed 
in the condition of the infection. The lack of improvement was un- 
doubtedly due to the fact that the patient was kept in a constant 
state of negative phase. 

Freeman, working in Wright's laboratory, noted the occurrence 
of autoinoculation following the manipulation and massage of af- 
fected joints in gonorrheal arthritis. Therefore, in the handling of 
localized infections one must always bear this fact in mind; that 
following any form of treatment, be it massage, X-ray, electric, radiant 
heat application or Bier's hyperemia, observations have shown the 
regular sequence of positive and negative phase and phase of in- 
creased resistance, identical with that produced by an ordinary vac- 
cine prepared from the invading organism. Therefore, when treating 
a patient with bacterial vaccines care must be taken to avoid over- 
manipulation of the infected area, as this may result in self -inoculation 
which would be equivalent to an overdose of bacterial vaccine. 

On the other hand, knowing as we do that the opsonins render the 
bacteria vulnerable to the phagocytes, it is very important to the 
success of the treatment that the lymph be made to flow through the 
infected tissues. In cases of infection, English authorities advise the 
use of a wet dressing compound of 4 per cent sodium chloride and .5 
per cent sodium citrate. This solution is an ideal lymphagogue, and 
prevents, by inhibiting coagulation, the formation of a scab. Let us 
remember also that leucocytes are essential to the success of vaccine 
therapy and that the best results may be expected when large num- 
bers of healthy leucocytes are present. MacWatter claims that the 
leucocytes may be increased in number 6 or 7 fold by the adminis- 
tration of yeast. This method is rather crude, as no definite amount 
of nucleinic acid is administered. As the success following the use of 
yeast in these cases is undoubtedly due to the nucleinic acid which it 



FAILURES FOLLOWING USE OF VACCINES 353 

contains, it would seem more scientific to use nucleinic acid which, 
under the name of nuclein solution, is readily obtainable. 

Some failures are due to the selection of unsuitable vaccines, as 
the following case will show: A young man suffering from chronic 
prostatitis came under my personal observation. Improvement was 
obtained by the use of gonococcus vaccine, but it seemed impossible 
by this means to effect a cure. At this stage, I resorted to the use 
of a combined vaccine made from a mixture of common pyogenic or- 
ganisms. The results of these injections were very gratifying. In 
this case, though the infection was primarily due to the gonococcus 
it is evident that other organisms replaced, at least in part, the one 
named. It should be borne in mind that though a specific organism 
may be the original cause of the trouble, the advent of other germs 
producing a mixed infection may delay a cure and, in the absence of 
indications to the contrary, it may be well in such cases to employ 
such a mixture of vaccines. 

CONCLUSIONS. 

1. There should be a proper determination of whether an antiserum 
or a bacterial vaccine is indicated. 2. Care should be exercised in de- 
ciding on the proper dosage for each individual infection. 3. The ad- 
ministration of vaccines during the aggravated stage of infection may 
produce harmful effects. 4. A proper interval should elapse before 
repeating the injections. 5. Too much local treatment of the infection 
may produce harmful results. 6. Such aids as tend toward the in- 
crease of leueocytosis or the freer movements of lymph should be 
given to assist the effects of the bacterial vaccine. 7. Any possible 
change in the character of the infection should be observed.